Influenza vaccine

ABSTRACT

The present invention relates to monovalent influenza vaccine formulations and vaccination regimes for immunising against influenza disease, their use in medicine, in particular their use in augmenting immune responses to various antigens, and to methods of preparation. In particular, the invention relates to monovalent influenza immunogenic compositions comprising an influenza antigen or antigenic preparation thereof from an influenza virus strain being associated with a pandemic outbreak or having the potential to be associated with a pandemic outbreak, in combination with an oil-in-water emulsion adjuvant comprising a metabolisable oil, a sterol and/or a tocopherol such as alpha tocopherol, and an emulsifying agent.

FIELD OF THE INVENTION

The present invention relates to influenza vaccine formulations andvaccination regimes for immunising against influenza disease, their usein medicine, in particular their use in augmenting immune responses tovarious antigens, and to methods of preparation. In particular, theinvention relates to monovalent influenza immunogenic compositionscomprising a low amount of influenza virus antigen or antigenicpreparation thereof from an influenza virus strain that is associatedwith a pandemic or has the potential to be associated with a pandemic,in combination with an oil-in-water emulsion adjuvant.

BACKGROUND OF THE INVENTION

Influenza viruses are one of the most ubiquitous viruses present in theworld, affecting both humans and livestock. Influenza results in aneconomic burden, morbidity and even mortality, which are significant.

The influenza virus is an RNA enveloped virus with a particle size ofabout 125 nm in diameter. It consists basically of an internalnucleocapsid or core of ribonucleic acid (RNA) associated withnucleoprotein, surrounded by a viral envelope with a lipid bilayerstructure and external glycoproteins. The inner layer of the viralenvelope is composed predominantly of matrix proteins and the outerlayer mostly of host-derived lipid material. Influenza virus comprisestwo surface antigens, glycoproteins neuraminidase (NA) andhaemagglutinin (HA), which appear as spikes, 10 to 12 nm long, at thesurface of the particles. It is these surface proteins, particularly thehaemagglutinin that determine the antigenic specificity of the influenzasubtypes. Virus strains are classified according to host species oforigin, geographic site and year of isolation, serial number, and, forinfluenza A, by serological properties of subtypes of HA and NA. 16 HAsubtypes (H1-H16) and nine NA subtypes (N1-N9) have been identified forinfluenza A viruses [Webster R G et al. Evolution and ecology ofinfluenza A viruses. Microbiol. Rev. 1992; 56:152-179; Fouchier R A etal. Characterization of a Novel Influenza A Virus Hemagglutinin Subtype(H16) Obtained from Black-Headed Gulls. J. Virol. 2005; 79:2814-2822).Viruses of all HA and NA subtypes have been recovered from aquaticbirds, but only three HA subtypes (H1, H2, and H3) and two NA subtypes(N1 and N2) have established stable lineages in the human populationsince 1918. Only one subtype of HA and one of NA are recognised forinfluenza B viruses.

Influenza A viruses evolve and undergo antigenic variabilitycontinuously [Wiley D, Skehel J. The structure and the function of thehemagglutinin membrane glycoprotein of influenza virus. Ann. Rev.Biochem. 1987; 56:365-394]. A lack of effective proofreading by theviral RNA polymerase leads to a high rate of transcription errors thatcan result in amino-acid substitutions in surface glycoproteins. This istermed “antigenic drift”. The segmented viral genome allows for a secondtype of antigenic variation. If two influenza viruses simultaneouslyinfect a host cell, genetic reassortment, called “antigenic shift” maygenerate a novel virus with new surface or internal proteins. Theseantigenic changes, both ‘drifts’ and ‘shifts’ are unpredictable and mayhave a dramatic impact from an immunological point of view as theyeventually lead to the emergence of new influenza strains and thatenable the virus to escape the immune system causing the well known,almost annual, epidemics. Both of these genetic modifications havecaused new viral variants responsible for pandemic in humans.

HA is the most important antigen in defining the serological specificityof the different influenza strains. This 75-80 kD protein containsnumerous antigenic determinants, several of which are in regions thatundergo sequence changes in different strains (strain-specificdeterminants) and others in regions which are common to many HAmolecules (common to determinants).

Influenza viruses cause epidemics almost every winter, with infectionrates for type A or B virus as high as 40% over a six-week period.Influenza infection results in various disease states, from asub-clinical infection through mild upper respiratory infection to asevere viral pneumonia. Typical influenza epidemics cause increases inincidence of pneumonia and lower respiratory disease as witnessed byincreased rates of hospitalization or mortality. The severity of thedisease is primarily determined by the age of the host, his immunestatus and the site of infection.

Elderly people, 65 years old and over, are especially vulnerable,accounting for 80-90% of all influenza-related deaths in developedcountries. Individuals with underlying chronic diseases are also mostlikely to experience such complications. Young infants also may suffersevere disease. These groups in particular therefore need to beprotected. Besides these ‘at risk’-groups, the health authorities arealso recommending to vaccinate health care providers.

Vaccination plays a critical role in controlling annual influenzaepidemics. Currently available influenza vaccines are either inactivatedor live attenuated influenza vaccine. Inactivated flu vaccines arecomposed of three possible forms of antigen preparation: inactivatedwhole virus, sub-virions where purified virus particles are disruptedwith detergents or other reagents to solubilise the lipid envelope(so-called “split” vaccine) or purified HA and NA (subunit vaccine).These inactivated vaccines are given intramuscularly (i.m.),subcutaneously (s.c.), or intranasally (i.n.).

Influenza vaccines for interpandemic use, of all kinds, are usuallytrivalent vaccines. They generally contain antigens derived from twoinfluenza A virus strains and one influenza B strain. A standard 0.5 mlinjectable dose in most cases contains (at least) 15 μg ofhaemagglutinin antigen component from each strain, as measured by singleradial immunodiffusion (SRD) (J. M. Wood et al.: An improved singleradial immunodiffusion technique for the assay of influenzahaemagglutinin antigen: adaptation for potency determination ofinactivated whole virus and subunit vaccines. J. Biol. Stand. 5 (1977)237-247; J. M. Wood et al., International collaborative study of singleradial diffusion and immunoelectrophoresis techniques for the assay ofhaemagglutinin antigen of influenza virus. J. Biol. Stand. 9 (1981)317-330).

Interpandemic influenza virus strains to be incorporated into influenzavaccine each season are determined by the World Health Organisation incollaboration with national health authorities and vaccinemanufacturers. Interpandemic Influenza vaccines currently available areconsidered safe in all age groups (De Donato et al. 1999, Vaccine, 17,3094-3101). However, there is little evidence that current influenzavaccines work in small children under two years of age. Furthermore,reported rates of vaccine efficacy for prevention of typical confirmedinfluenza illness are 23-72% for the elderly, which are significantlylower than the 60-90% efficacy rates reported for younger adults(Govaert, 1994, J. Am. Med. Assoc., 21, 166-1665; Gross, 1995, AnnIntern. Med. 123, 523-527). The effectiveness of an influenza vaccinehas been shown to correlate with serum titres of hemagglutinationinhibition (HI) antibodies to the viral strain, and several studies havefound that older adults exhibit lower HI titres after influenzaimmunisation than do younger adults (Murasko, 2002, Experimentalgerontology, 37, 427-439).

A sub-unit influenza vaccine adjuvanted with the adjuvant MF59, in theform of an oil-in-water emulsion is commercially available for theelderly and at risk population, and has demonstrated its ability toinduce a higher antibody titer than that obtained with thenon-adjuvanted sub-unit vaccine (De Donato et al. 1999, Vaccine, 17,3094-3101). However, in a later publication, the same vaccine has notdemonstrated its improved profile compared to a non-adjuvanted splitvaccine (Puig-Barbera et al., 2004, Vaccine 23, 283-289).

By way of background, during inter-pandemic periods, influenza virusesthat circulate are related to those from the preceding epidemic. Theviruses spread among people with varying levels of immunity frominfections earlier in life. Such circulation, over a period of usually2-3 years, promotes the selection of new strains that have changedenough to cause an epidemic again among the general population; thisprocess is termed ‘antigenic drift’. ‘Drift variants’ may have differentimpacts in different communities, regions, countries or continents inany one year, although over several years their overall impact is oftensimilar. Typical influenza epidemics cause increases in incidence ofpneumonia and lower respiratory disease as witnessed by increased ratesof hospitalisation or mortality. The elderly or those with underlyingchronic diseases are most likely to experience such complications, butyoung infants also may suffer severe disease.

At unpredictable intervals, novel influenza viruses emerge with a keysurface antigen, the haemagglutinin, of a totally different subtype fromstrains circulating the season before. Here, the resulting antigens canvary from 20% to 50% from the corresponding protein of strains that werepreviously circulating in humans. This can result in virus escaping‘herd immunity’ and establishing pandemics. This phenomenon is called‘antigenic shift’. In other words, an influenza pandemics occurs when anew influenza virus appears against which the human population has noimmunity. It is thought that at least the past pandemics have occurredwhen an influenza virus from a different species, such as an avian or aporcine influenza virus, has crossed the species barrier. If suchviruses have the potential to spread from human to human, they mayspread worldwide within a few months to a year, resulting in a pandemic.For example, in 1957 (Asian Flu pandemic), viruses of the H2N2 subtypereplaced H1N1 viruses that had been circulating in the human populationsince at least 1918 when the virus was first isolated. The H2 HA and N2NA underwent antigenic drift between 1957 and 1968 until the HA wasreplaced in 1968 (Hong-Kong Flu pandemic) by the emergence of the H3N2influenza subtype, after which the N2 NA continued to drift along withthe H3 HA (Nakajima et al., 1991, Epidemiol. Infect. 106, 383-395).

The features of an influenza virus strain that give it the potential tocause a pandemic outbreak are: it contains a new haemagglutinin comparedto the haemagglutinin in the currently circulating strains, which may ornot be accompanied by a change in neuraminidase subtype; it is capableof being transmitted horizontally in the human population; and it ispathogenic for humans. A new haemagglutinin may be one which has notbeen evident in the human population for an extended period of time,probably a number of decades, such as H2. Or it may be a haemagglutininthat has not been circulating in the human population before, forexample H5, H9, H7 or H6 which are found in birds. In either case themajority, or at least a large proportion of, or even the entirepopulation has not previously encountered the antigen and isimmunologically naïve to it.

Several clinical studies have been performed to evaluate safety andimmunogenicity in unprimed populations, with monovalent candidatevaccines containing a pandemic strain such as the non-circulating H2N2or H9N2 strains. Studies have investigated split or whole virusformulations of various HA concentrations (1.9, 3.8, 7.5 or 15 μg HA perdose), with or without alum adjuvantation. Influenza viruses of the H2N2subtype circulated from 1957 until 1968 when they were replaced by H3N2strains during the ‘Hong Kong pandemic’. Today, individuals that wereborn after 1968 are immunologically naïve to H2N2 strains. These vaccinecandidates have been shown to be immunogenic and well tolerated. Resultsare reported in Hehme, N et al. 2002, Med. Microbiol. Immunol. 191,203-208; in Hehme N. et al. 2004, Virus Research 103, 163-171; and twostudies were reported with H5N1 (Bresson J L et al. The Lancet. 2006:367(9523):1657-1664; Treanor J J et al. N Engl J Med. 2006; 354:1343-1351).Other studies have reported results with MF59 adjuvanted influenzavaccines. One study has reported that two doses of an H5N3 influenzavaccine adjuvanted with MF59 was boosting immunity to influenza H5N1 ina primed population (Stephenson et al., Vaccine 2003, 21, 1687-1693) andanother study has reported cross-reactive antibody responses to H5N1viruses obtained after three doses of MF59-adjuvanted influenza H5N3vaccine (Stephenson et al., J. Infect. Diseases 2005, 191, 1210-1215).

Persons at risk in case of an influenza pandemic may be different fromthe defined risk-groups for complications due to seasonal influenza.According to the WHO, 50% of the human cases caused by the avianinfluenza strain H5N1 occurred in people below 20 years of age, 90%occurred among those aged <40. (WHO, weekly epidemiological record, 30Jun. 2006).

During a pandemic, antiviral drugs may not be sufficient or effective tocover the needs and the number of individuals at risk of influenza willbe greater than in interpandemic periods, therefore the development of asuitable vaccine with the potential to be produced in large amounts andwith efficient distribution and administration potential is essential.For these reasons, monovalent instead of trivalent vaccines are beingdeveloped for pandemic purposes in an attempt to reduce vaccine volume,primarily as two doses of vaccine may be necessary in order to achieveprotective antibody levels in immunologically naïve recipients (Wood J Met al. Med Mircobiol Immunol. 2002; 191:197-201. Wood J M et al. PhilosTrans R Soc Lond B Biol Sci. 2001; 356:1953-1960).

These problems may be countered by adjuvantation, the aim of which is toincrease immunogenicity of the vaccine in order to be able to decreasethe antigen content (antigen sparing) and thus increase the number ofvaccine doses available. The use of an adjuvant may also overcome thepotential weak immunogenicity of the antigen in a naïve population.Examples of the above have been shown using whole inactivated H2N2 orH9N2 virus adjuvanted with aluminium salt (N. Hehme et al. VirusResearch 2004, 103, 163-171). Clinical trials with plain subvirion H5N1vaccine or aluminium hydroxide adjuvanted split virus H5N1 vaccine havealready been performed. The results of these trials indicate that bothplain and adjuvanted H5N1 virus vaccines are safe up to an antigen doseof 90 μg (tested only as plain subvirion vaccine) (Bresson J L et al.The Lancet. 2006:367 (9523):1657-1664; Treanor J J et al. N Engl J Med.2006; 354:1343-1351)

New vaccines with an improved immunogenicity, in particular againstweakly or non-immunogenic pandemic strains or for the immuno-compromisedindividuals such as the elderly population, are therefore still needed.New vaccines with a cross-protection potential are also needed, thatcould be used as pre-pandemic or stockpiling vaccines to prime animmunologically naive population against a pandemic strain before orupon declaration of a pandemic. Formulation of vaccine antigen withpotent adjuvants is a possible approach for enhancing immune responsesto subvirion antigens. Novel adjuvant formulations are hereby providedwhich allow an antigen sparing formulation affording sufficientprotection (seroconversion of previously seronegative subjects to a HItiter considered as protective, 1:40 or fourfold increase in titer) ofall age groups.

SUMMARY OF THE INVENTION

In first aspect of the present invention, there is provided an influenzaimmunogenic composition, in particular a vaccine, comprising a lowamount of influenza virus antigen or antigenic preparation from aninfluenza virus strain that is associated with a pandemic or has thepotential to be associated with a pandemic, in combination with anadjuvant, wherein the low antigen amount does not exceed 15 μg ofhaemagglutinin (HA) per dose, and wherein said adjuvant is anoil-in-water emulsion comprising a metabolisable oil, a sterol and/or atocopherol, such as alpha tocopherol, and an emulsifying agent. Suitablythe vaccine composition is a monovalent composition.

Throughout the document it will be referred to a pandemic strain as aninfluenza strain being associated or susceptible to be associated withan outbreak of influenza disease, such as pandemic Influenza A strains.Suitable strains are in particular avian (bird) influenza strains.Suitable pandemic strains are, but not limited to: H5N1 (the highlypathogenic avian H5N1 strain, now endemic in many bird species acrossthe world, is a candidate pandemic strain according to this invention),H9N2, H7N7, H2N2, H7N1 and H1N1. Others suitable pandemic strains inhuman are H7N3 (2 cases reported in Canada), H10N7 (2 cases reported inEgypt) and H5N2 (1 case reported in Japan).

In another aspect, the invention provides a method for the production ofan influenza immunogenic composition, in particular a vaccine, for apandemic situation or a pre-pandemic situation which method comprisesadmixing an influenza virus antigen or antigenic preparation thereoffrom a single influenza virus strain that is associated with a pandemicor has the potential to be associated with a pandemic, with anoil-in-water emulsion adjuvant as herein above defined, and providingvaccine units which contain no more than 15 (g influenza haemagglutininantigen per dose. The influenza virus may be egg-derived, plant-derived,cell-culture derived, or may be recombinantly produced. Suitably theinfluenza virus antigen is egg-derived or cell culture-derived.

In a third aspect, there is provided an immunogenic composition asherein defined for use in medicine.

In yet another aspect there is provided the use of (a) a low amount, asherein defined, of influenza virus antigen or antigenic preparationthereof from a single strain of influenza associated with a pandemic orhaving the potential to be associated with a pandemic, and (b) anoil-in-water emulsion adjuvant, in the manufacture of an immunogeniccomposition, or a kit, for inducing at least one of i) an improved CD4T-cell immune response, ii) an improved B cell memory response, iii) animproved humoral response, against said virus antigen or antigeniccomposition in a human. Said immune response is in particular induced inan immuno-compromised individual or population, such as a high riskadult or an elderly. Suitably the immunogenic composition is as hereindefined.

There is also provided the use of an influenza virus or antigenicpreparation thereof and an oil-in-water emulsion adjuvant in thepreparation of an immunogenic composition as herein defined forvaccination of human elderly against influenza.

In a specific embodiment, the immunogenic composition is capable ofinducing both an improved CD4 T-cell immune response and an improvedB-memory cell response compared to that obtained with the un-adjuvantedantigen or antigenic composition. In another specific embodiment, theimmunogenic composition is capable of inducing both an improved CD4T-cell immune response and an improved humoral response compared to thatobtained with the un-adjuvanted antigen or antigenic composition. Inparticular, said humoral immune response or protection meets at leastone, suitably two typically all three EU or FDA regulatory criteria forinfluenza vaccine efficacy. Suitably, said immune response(s) orprotection is obtained after one, suitably two, doses of vaccine.Specifically said immune response(s) or protection meets at least one,suitably two or all three EU or FDA regulatory criteria for influenzavaccine efficacy after one dose of adjuvanted vaccine. Specifically atleast one, suitably two FDA or EU criteria is (are) met after only onedose of vaccine. Efficacy criteria for the composition according to thepresent invention are further detailed below (see Table 1 and belowunder “efficacy criteria”). Suitably said composition is administeredparenterally, in particular via the intramuscular or the sub-cutaneousroute.

In a further embodiment, there is provided the use of a low amount of aninfluenza virus or antigenic preparation thereof in the manufacture ofan immunogenic composition for revaccination of humans previouslyvaccinated with a monovalent influenza immunogenic compositioncomprising an influenza antigen or antigenic preparation thereof from asingle influenza virus strain which is associated with a pandemic or hasthe potential to be associated with a pandemic, in combination with anoil-in-water emulsion adjuvant as herein defined.

In a specific embodiment, the composition used for the revaccination maybe un-adjuvanted or may contain an adjuvant, in particular anoil-in-water emulsion adjuvant. In another specific embodiment, theimmunogenic composition for revaccination contains an influenza virus orantigenic preparation thereof which shares common CD4 T-cell epitopeswith the influenza virus or virus antigenic preparation thereof used forthe first vaccination. The immunogenic composition for a revaccinationmay contain a classical amount (i.e., about 15 μg of HA) of said variantpandemic strain.

Suitably the revaccination is made in subjects who have been vaccinatedthe previous season against influenza. Suitably, the revaccination ismade with a vaccine comprising an influenza strain (e.g. H5N1 Vietnam)which is of the same subtype as that used for the first vaccination(e.g. H5N1 Vietnam). In a specific embodiment, the revaccination is madewith a drift strain of the same sub-type, e.g. H5N1 Indonesia. Inanother embodiment, said influenza strain used for the revaccination isa shift strain, i.e., is different from that used for the firstvaccination, e.g. it has a different HA or NA subtype, such as H5N2(same HA subtype as H5N1 but different NA subtype) or H7N1 (different HAsubtype from H5N1 but same NA subtype).

Suitably the first vaccination is made at the declaration of a pandemicand revaccination is made later. Alternatively the first vaccination ispart of a pre-pandemic strategy and is made before the declaration of apandemic, as a priming strategy, thus allowing the immune system to beprimed, with the revaccination made subsequently. In this instance oneor two doses of vaccine containing the same influenza strain areadministered as part of the primo-vaccination. Revaccination, inparticular with a variant (e.g. drift) strain, can be made at any timeafter the first course (one or two doses) of vaccination. Typicallyrevaccination is made at least 1 month, suitably at least two months,suitably at least three months, or 4 months after the first vaccination,suitably 6 or 8 to 14 months after, suitably at around 10 to 12 monthsafter or even longer. Suitably revaccination one year later or even morethan one year later is capable of boosting antibody and/or cellularimmune response. This is especially important as further waves ofinfection may occur several months after the first outbreak of apandemic. As needed, revaccination may be made more than once.

Suitably said oil-in-water emulsion comprises a metabolisable oil, asterol and/or a tocopherol, such as alpha tocopherol, and an emulsifyingagent. In a another specific embodiment, said oil-in-water emulsionadjuvant comprises at least one metabolisable oil in an amount of 0.5%to 20% of the total volume, and has oil droplets of which at least 70%by intensity have diameters of less than 1 μm. Suitably said atocopherol, such as alpha tocopherol, is present in an amount of 1.0% to20%, in particular in an amount of 1.0% to 5% of the total volume ofsaid immunogenic composition.

In a further aspect of the present invention, there is provided the useof an antigen or antigenic preparation from a first pandemic influenzastrain in the manufacture of an immunogenic composition as hereindefined for protection against influenza infections caused by a variantinfluenza strain.

In a specific aspect, there is provided a method of vaccination of animmuno-compromised human individual or population such as high riskadults or elderly, said method comprising administering to saidindividual or population an influenza immunogenic composition comprisinga low amount of an influenza antigen or antigenic preparation thereoffrom a single pandemic influenza virus strain in combination with anoil-in-water emulsion adjuvant as herein defined.

In still another embodiment, the invention provides a method forrevaccinating humans previously vaccinated with a monovalent influenzaimmunogenic composition comprising an influenza antigen or antigenicpreparation thereof from a single pandemic influenza virus strain, incombination with an oil-in-water emulsion adjuvant, said methodcomprising administering to said human an immunogenic compositioncomprising an influenza virus, either adjuvanted or un-adjuvanted.

In a further embodiment there is provided a method for vaccinating ahuman population or individual against one pandemic influenza virusstrain followed by revaccination of said human or population against avariant influenza virus strain, said method comprising administering tosaid human (i) a first composition comprising an influenza virus orantigenic preparation thereof from a first pandemic influenza virusstrain and an oil-in-water emulsion adjuvant, and (ii) a secondimmunogenic composition comprising a influenza virus strain variant ofsaid first influenza virus strain. In a specific embodiment said variantstrain is associated with a pandemic or has the potential to beassociated with a pandemic. In another specific embodiment said variantstrain is part of a multivalent composition which comprises, in additionto said pandemic influenza virus variant, at least one circulating(seasonal) influenza virus strain. In particular, said pandemicinfluenza virus strain is part of a bivalent, or a trivalent, ortetravalent composition additionally comprising one, two or threeseasonal strains, respectively.

Throughout the document, the use of a low amount of pandemic influenzavirus antigen in the manufacture of a composition as herein defined forprevention of influenza infection or disease, and a method of treatmentof humans using the claimed composition will be interchangeably used.

Other aspects and advantages of the present invention are describedfurther in the following detailed description of preferred embodimentsthereof.

LEGEND TO FIGURES

FIG. 1A and FIG. 1B: Oil droplet particle size distribution in SB62oil-in-water emulsion as measured by PCS. FIG. 1A shows SB62 lot 1023size measurements with the Malvern Zetasizer 3000HS: A=dilution 1/10000(Rec22 to Rec24) (Analysis in Contin and adapted optical model1.5/0.01); B=Dilution 1/20000 (Rec28 to Rec30) (Analysis in Contin andadapted optical model 1.5/0.01). FIG. 1B shows a schematic illustrationof record 22 (upper part) and record 23 (lower part) by intensity.

FIG. 2A and FIG. 2B: Ferrets experiments. FIG. 2A: HemagglutinationInhibition test (GMT) in ferrets immunized with different doses of H5N1A/Vietnam. FIG. 2B: Mean H5N1 PCR data (upper graph) and mean virustitration data (lower graph) of lung tissues from ferrets on day ofdeath or euthanisation (PCR data are expressed as Control Dilution Units(CDU) which are determined from a standard curve produced from a stockof virus which is serially diluted, with each dilution undergoingnucleic acid extraction and TAQMAN™. PCR amplification in the samemanner as test samples. Virus titration data is expressed as TCID₅₀/gtissue).

FIG. 3: Anti-A/Vietnam neutralizing antibody responses in ferretsimmunized with different doses of H5N1 A/Vietnam.

FIG. 4: Overview of the manufacture of influenza monovalent bulks.

FIG. 5: Formulation flow sheet for final bulk of antigen

FIG. 6: Human clinical trial with a dose-range of H5N1 split virusantigen, adjuvanted or not with AS03. GMT's (with 95% CI) for anti-HAantibody at time-points days 0, 21 and 42.

FIG. 7: Human clinical trial with a dose-range of H5N1 split virusantigen, adjuvanted or not with AS03. Seroconversion rates (with 95% CI)for anti-HA antibody at post-vaccination day 21 and day 42.

FIG. 8: Human clinical trial with a dose-range of H5N1 split virusantigen, adjuvanted or not with AS03. Seroprotection rates (with 95% CI)for anti-HA antibody at each time-points (Day 0, Day 21 and Day 42).

FIG. 9: Human clinical trial with a dose-range of H5N1 split virusantigen, adjuvanted or not with AS03. Seroconversion factor (with 95%CI) for anti-HA antibody at post-vaccination (day 21 and 42)

FIG. 10A1, FIG. 10A2, FIG. 10B1 and FIG. 10B2, FIG. 10C, and FIG. 10D:Neutralisation titers to H5N1 Vietnam strain. The results of a partialanalysis of a Hemagglutination Inhibition test (GMT) is shown in FIG.10A1 and the results of a total analysis of a HemagglutinationInhibition test (GMT) is shown in FIG. 10A2. The results of a partialanalysis of seroconversion rates for neutralizing antibody titer isshown in FIG. 10B1 and the results of a total analysis of seroconversionrates for neutralizing antibody titer is shown in FIG. 10B2.HN4=non-adjuvanted 3.8 μg HA; HN8=non-adjuvanted 7.5 μg HA; HN4AD=AS03adjuvanted 3.8 μg HA; HN8AD=AS03 adjuvanted 7.5 μg HA. FIG. 10C showsGMT (95% CI) for the neutralizing antibodies against Indonesia strain(ATP cohort immunogenicity). FIG. 10D shows seroconversion rates (with95% CI) for the neutalizing antibodies against Indonesia strain (ATPcohort for immunogenicity).

FIG. 11: CD 4 Specific response to H5N1 Vietnam strain.HN4=non-adjuvanted 3.8 μg HA; H N8=non-adjuvanted 7.5 μg HA; HN4AD=AS03adjuvanted 3.8 μg HA; HN8AD=AS03 adjuvanted 7.5 μg HA.

FIG. 12: H5N1-specific serum IgG ELISA titers in C57Bl/6 naive mice(GMT+/−IC95).

FIG. 13: Hemagglutination Inhibition test (GMT+/−IC95) in C57Bl/6 naivemice immunized with different doses of H5N1 A/Vietnam.

FIG. 14: Anti-H5N1 A/Vietnam (upper panel) and anti-H5N1 A/Indonesia(lower panel) neutralizing antibody responses (GMT) in ferrets immunizedwith different doses of adjuvanted H5N1 A/Vietnam vaccines, thenon-adjuvanted H5N1 A/Vietnam vaccine or the adjuvant alone.

FIG. 15: Mean virus titration data by viral culture of lung tissues fromferrets challenge with heterologous H5N1 viruses.

FIG. 16: H5N1-specific CD4+ T cell responses induced by different dosesof adjuvanted H5N1 split vaccines.

DESCRIPTION OF THE INVENTION

The present inventors have discovered that an influenza formulationcomprising low amount of an influenza virus or antigenic preparationthereof associated with a pandemic or susceptible to be associated witha pandemic, together with an oil-in-water emulsion adjuvant comprising ametabolisable oil, a sterol and/or a tocopherol, such as alphatocopherol, and an emulsifying agent, was capable of improving thehumoral immune response, and/or the CD4 T-cell immune response and/or Bcell memory response against said antigen or antigenic composition in ahuman or population, compared to that obtained with the un-adjuvantedvirus or antigenic preparation thereof. They will allow one to achieveprotection against morbidity/mortality caused by a homologous influenzastrain. The formulations adjuvanted with an oil-in-water emulsionadjuvant as herein defined will advantageously be used to induceanti-influenza CD4-T cell response capable of detection of influenzaepitopes presented by MHC class II molecules. The formulationsadjuvanted with an oil-in-water emulsion adjuvant as herein defined willadvantageously be used to induce a cross-reactive immune response, i.e.,detectable immunity (humoral and/or cellular) against a variant strainor against a range of related strains. The adjuvanted formulations willadvantageously be effective to target the humoral and/or thecell-mediated immune system in order to increase responsiveness againsthomologous and drift influenza strains (upon vaccination and infection).They will also advantageously be used to induce, after one or two doses,a cross-priming strategy, i.e., induce “primed” immunological memoryfacilitating response upon revaccination (one-dose) with a variantstrain. In this case i.e., after a course of pre-pandemic vaccine(administered in one or two doses), a recipient would need just one doseof pandemic vaccine (instead of two), to be fully protected against theactual pandemic strain.

The adjuvanted pandemic influenza compositions according to theinvention have several advantages:

-   -   1) An improved immunogenicity: they will allow to improve weak        immune response to less immunogenic influenza strains to level        higher than those obtained with the un-adjuvanted formulations;    -   2) The use of adjuvants can overcome the potential weak        immunogenicity of the antigen in a naïve population;    -   3) They may lead to an improved immunogenicity in specific        populations such as in the elderly people (typically over 60        years of age) to levels seen in younger people aged 18 to 60        (antibody and/or T cell responses);    -   4) They may lead to an improved cross-protection profile:        increased cross-reactivity, cross-protection against variant        (drifted) influenza strains allowing the set-up of a        cross-priming strategy where they can be used as pre-pandemic        vaccines further allowing only one dose of a pandemic vaccine to        be required to enhance the protection against the (circulating)        pandemic strain;    -   5) By reaching any or all of these further advantages with a        reduced antigen dosage, they will ensure an increased capacity        in case of emergency or for preparedness of a pandemic situation        (antigen-sparing in the pandemic situation) and offering a        possibility of higher number of vaccine doses available to the        population.

Other advantages will be apparent from the description and the examplesection below. The compositions for use in the present invention may beable to provide better sero-protection against influenza followingrevaccination, as assessed by the number of human subjects meeting theinfluenza correlates of protections. Furthermore, the composition foruse in the present invention may also be able to induce a higher humoralresponse or B cell memory response following the first vaccination of ahuman subject, and a higher response following revaccination, comparedto the non-adjuvanted composition.

The claimed adjuvanted compositions may also be able not only to inducebut also maintain protective levels of antibodies against the influenzastrain present in the vaccine, in more individuals than those obtainedwith the un-adjuvanted composition.

Thus, in still another embodiment, the claimed composition is capable ofensuring a persistent immune response against influenza related disease.In particular, by persistence it is meant an HI antibody immune responsewhich is capable of meeting regulatory criteria after at least threemonths, suitably after at least 6 months after the vaccination. Inparticular, the claimed composition is able to induce protective levelsof antibodies as measured by the protection rate (see Table 1) in >50%,suitably in >60% of individuals >70% of individuals, suitably in >80% ofindividuals or suitably in >90% of individuals for the pandemicinfluenza strain present in the vaccine, after at least three months. Ina specific aspect, protective levels of antibodies of >90% are obtainedat least 6 months post-vaccination against the influenza strain of thevaccine composition.

According to further aspects of the present invention, the claimedcomposition is capable to induce seroprotection and seroconversion to ahigher degree than that provided for by the EU requirements for vaccineinfluenza strains. This will be further detailed below (see Table 1 andbelow under “efficacy criteria”).

Influenza Viral Strains and Antigens

In one embodiment, an influenza virus or antigenic preparation thereoffor use according to the present invention may be a split influenzavirus or split virus antigenic preparation thereof. In an alternativeembodiment the influenza preparation may contain another type ofinactivated influenza antigen, such as inactivated whole virus orrecombinant and/or purified HA and NA (subunit vaccine), or an influenzavirosome. In a still further embodiment, the influenza virus may be alive attenuated influenza preparation.

A split influenza virus or split virus antigenic preparation thereof foruse according to the present invention is suitably an inactivated viruspreparation where virus particles are disrupted with detergents or otherreagents to solubilise the lipid envelope. Split virus or split virusantigenic preparations thereof are suitably prepared by fragmentation ofwhole influenza virus, either infectious or inactivated, withsolubilising concentrations of organic solvents or detergents andsubsequent removal of all or the majority of the solubilising agent andsome or most of the viral lipid material. By split virus antigenicpreparation thereof is meant a split virus preparation which may haveundergone some degree of purification compared to the split virus whilstretaining most of the antigenic properties of the split viruscomponents. For example, when produced in eggs, the split virus may bedepleted from egg-contaminating proteins, or when produced in cellculture, the split virus may be depleted from host cell contaminants. Asplit virus antigenic preparation may comprise split virus antigeniccomponents of more than one viral strain. Vaccines containing splitvirus (called ‘influenza split vaccine’) or split virus antigenicpreparations generally contain residual matrix protein and nucleoproteinand sometimes lipid, as well as the membrane envelope proteins. Suchsplit virus vaccines will usually contain most or all of the virusstructural proteins although not necessarily in the same proportions asthey occur in the whole virus.

Alternatively, the influenza virus may be in the form of a whole virusvaccine. This may prove to be an advantage over a split virus vaccinefor a pandemic situation as it avoids the uncertainty over whether asplit virus vaccine can be successfully produced for a new strain ofinfluenza virus. For some strains the conventional detergents used forproducing the split virus can damage the virus and render it unusable.Although there is always the possibility to use different detergentsand/or to develop a different process for producing a split vaccine,this would take time, which may not be available in a pandemicsituation. In addition to the greater degree of certainty with a wholevirus approach, there is also a greater vaccine production capacity thanfor split virus since considerable amounts of antigen are lost duringadditional purification steps necessary for preparing a suitable splitvaccine.

In another embodiment, the influenza virus preparation is in the form ofa purified sub-unit influenza vaccine. Sub-unit influenza vaccinesgenerally contain the two major envelope proteins, HA and NA, and mayhave an additional advantage over whole virion vaccines as they aregenerally less reactogenic, particularly in young vaccinees. Sub-unitvaccines can be produced either recombinantly or purified from disruptedviral particles.

In another embodiment, the influenza virus preparation is in the form ofa virosome. Virosomes are spherical, unilamellar vesicles which retainthe functional viral envelope glycoproteins HA and NA in authenticconformation, intercalated in the virosomes' phospholipids bilayermembrane.

Said influenza virus or antigenic preparation thereof may be egg-derivedor cell-culture derived. They may also be produced in other systems suchas insect cells, plants, yeast or bacteria or be recombinantly produced.

For example, the influenza virus antigen or antigenic preparationsthereof according to the invention may be derived from the conventionalembryonated egg method, by growing influenza virus in eggs and purifyingthe harvested allantoic fluid. Eggs can be accumulated in large numbersat short notice. Alternatively, they may be derived from any of the newgeneration methods using tissue culture to grow the virus or expressrecombinant influenza virus surface antigens. Suitable cell substratesfor growing the virus include for example dog kidney cells such as MDCKor cells from a clone of MDCK, MDCK-like cells, monkey kidney cells suchas AGMK cells including Vero cells, suitable pig cell lines, or anyother mammalian cell type suitable for the production of influenza virusfor vaccine purposes. Suitable cell substrates also include human cellse.g. MRC-5 or Per-C6 cells. Suitable cell substrates are not limited tocell lines; for example primary cells such as chicken embryo fibroblastsand avian cell lines are also included.

The influenza virus antigen or antigenic preparation thereof may beproduced by any of a number of commercially applicable processes, forexample the split flu process described in patent no. DD 300 833 and DD211 444, incorporated herein by reference. Traditionally split flu wasproduced using a solvent/detergent treatment, such as tri-n-butylphosphate, or diethylether in combination with TWEEN™ (known as“Tween-ether” splitting) and this process is still used in someproduction facilities. Other splitting agents now employed includedetergents or proteolytic enzymes or bile salts, for example sodiumdeoxycholate as described in patent no. DD 155 875, incorporated hereinby reference. Detergents that can be used as splitting agents includecationic detergents e.g. cetyl trimethyl ammonium bromide (CTAB), otherionic detergents e.g. laurylsulfate, taurodeoxycholate, orsodium-dodecyl sulfate or non-ionic detergents such as the onesdescribed above including TRITON X-100™ (Octylphenol ethoxylate) (forexample in a process described in Lina et al, 2000, Biologicals 28,95-103) and TRITON™ N-101, or combinations of any two or moredetergents.

The preparation process for a split vaccine may include a number ofdifferent filtration and/or other separation steps such asultracentrifugation, ultrafiltration, zonal centrifugation andchromatography (e.g. ion exchange) steps in a variety of combinations,and optionally an inactivation step e.g., with heat, formaldehyde orβ-propiolactone or U.V. irradiation which may be carried out before orafter splitting. The splitting process may be carried out as a batch,continuous or semi-continuous process. A suitable splitting andpurification process for a split immunogenic composition is described inWO 02/097072.

Suitable split flu vaccine antigen preparations according to theinvention comprise a residual amount of TWEEN™ (known as “Tween-ether”splitting) 80 and/or TRITON X100™ (Octylphenol ethoxylate) remainingfrom the production process, although these may be added or theirconcentrations adjusted after preparation of the split antigen. Suitablyboth TWEEN™ (known as “Tween-ether” splitting) 80 and TRITON X100™(Octylphenol ethoxylate) are present. Suitable ranges for the finalconcentrations of these non-ionic surfactants in the vaccine dose are:

TWEEN™ (known as “Tween-ether” splitting) 80: 0.01 to 1%, suitably about0.1% (v/v)TRITON X100™ (Octylphenol ethoxylate): 0.001 to 0.1 (% w/v), suitably0.005 to 0.02% (w/v).

In a specific embodiment, the final concentration for TWEEN™ (known as“Tween-ether” splitting) 80 ranges from 0.045%-0.09% w/v. In anotherspecific embodiment, the antigen is provided as a 2-fold concentratedmixture, which has a TWEEN™ (known as “Tween-ether” splitting) 80concentration ranging from 0.045%-0.2% (w/v) and has to be diluted twotimes upon final formulation with the adjuvanted (or the buffer in thecontrol formulation).

In another specific embodiment, the final concentration for TRITON X100™(Octylphenol ethoxylate) ranges from 0.005%-0.017% w/v. In anotherspecific embodiment, the antigen is provided as a 2 fold concentratedmixture, which has a TRITON X100™ (Octylphenol ethoxylate) concentrationranging from 0.005%-0.034% (w/v) and has to be diluted two times uponfinal formulation with the adjuvanted (or the buffer in the controlformulation).

The influenza preparation may be prepared in the presence of apreservative such as thiomersal. Suitably the preservative, inparticular thiomersal, is present at a concentration of around 100μg/ml. Alternatively, the influenza preparation is prepared in thepresence of low level of preservative in particular thiomersal, such asa concentration not exceeding 20 μg/ml or suitably less than 5 μg/ml. Inanother suitable alternative embodiment, the influenza preparation ismade in the absence of thiomersal. Suitably the resulting influenzapreparation is stable in the absence of organomercurial preservatives,in particular the preparation contains no residual thiomersal. Inparticular the influenza virus preparation comprises a haemagglutininantigen stabilised in the absence of thiomersal, or at low levels ofthiomersal (generally 5 μg/ml or less). Specifically the stabilizationof B influenza strain is performed by a derivative of alpha tocopherol,such as alpha tocopherol succinate (also known as vitamin E succinate,i.e., VES). Such preparations and methods to prepare them are disclosedin WO 02/097072.

Alternatively, especially for multi-dose containers, thiomersal or anyother suitable preservative is present in order to reduce thecontamination risks. This is particularly of relevance for pandemicvaccines, designed to vaccinate as many people as possible in theshortest possible time.

A suitable composition for revaccination contains three inactivatedsplit virion antigens prepared from the WHO recommended strains of theappropriate influenza season, in addition to a pandemic influenzastrain.

In one embodiment the influenza virus or antigenic preparation thereofand the oil-in-water emulsion adjuvant are contained in the samecontainer. It is referred to as ‘one vial approach’. Suitably the vialis a pre-filled syringe or a 10-dose multi-dose vial or a 12-doseampoule. In an alternative embodiment, the influenza virus or antigenicpreparation thereof and the oil-in-water emulsion adjuvant are containedin separate containers or vials or units and admixed shortly before orupon administration into the subject. It is referred to as ‘two vialsapproach’. By way of example, when the vaccine is a 2 components vaccinefor a total dose volume of injected dose of 0.5 ml, the concentratedantigens (for example the concentrated inactivated split virionantigens) may be presented in one vial (330 μl) (antigen container, suchas a vial) and a pre-filled syringe contains the adjuvant (400 μl)(adjuvant container, such as a syringe). Typically, the pandemic vaccineis a 0.5 ml injected dose and multidose vials contain a 1:1 vial:vialmixture prior to first subject injected. Alternatively, the pandemicvaccine is a 1.0 ml vial:syringe injected dose. At the time ofinjection, the content of the vial containing the concentratedinactivated split virion antigens is removed from the vial by using thesyringe containing the adjuvant followed by gentle mixing of thesyringe. Prior to injection, the used needle is replaced by anintramuscular needle and the volume is corrected to 530 μl. One dose ofthe reconstituted adjuvanted influenza vaccine candidate corresponds to530 μl.

Suitably the adjuvanted pandemic influenza candidate vaccine is a 2component vaccine consisting of 0.5 ml of concentrated inactivated splitvirion antigens presented in a type I glass vial and of a pre-filledtype I glass syringe containing 0.5 ml of the adjuvant. Alternativelythe vaccine is a 2 components vaccine presented in 2 vials (one for theantigen one for the adjuvant, of 10 doses each) for mixture prior to theadministration to the first patient within 24 hours at room temperatureand subsequent storage at 4° C. for a short period of time (e.g. up toone week) for subsequent administration. At the time of injection, thecontent of the multi-dose vial or the syringe containing the adjuvant isinjected into the vial that contains the concentrated split virionantigen. After mixing the content is withdrawn into the syringe and theneedle is replaced by an intramuscular needle. One dose of thereconstituted adjuvanted influenza candidate vaccine corresponds to 0.5ml. Each vaccine dose of 0.5 ml contains a low dose of haemagglutinin(HA), such as a dose less than 15 μg of HA, suitably less than 10 μg.Suitable amounts are 1.9 μg, 3.8 μg, 7.5 μg, or 10 μg HA or any suitableamount of HA lower than 15 μg which would have be determined such thatthe vaccine composition meets the efficacy criteria as defined herein.Advantageously an HA dose of 1 μg of HA or even less such as 0.5 μg ofHA that would allow meeting the regulatory criteria defined above may beused. A vaccine dose of 0.5 ml is suitably used. A vaccine dose of 1 ml(0.5 ml adjuvant plus 0.5 ml antigen preparation) is also suitable.

According to the present invention, the influenza strain in themonovalent immunogenic composition as herein defined is associated witha pandemic or has the potential to be associated with a pandemic. Suchstrain may also be referred to as ‘pandemic strains’ in the text below.In particular, when the vaccine is a multivalent vaccine forrevaccination, such as a bivalent, or a trivalent or a quadrivalentvaccine, at least one strain is associated with a pandemic or has thepotential to be associated with a pandemic. Suitable strains are, butnot limited to: H5N1, H9N2, H7N7, H2N2, H7N1 and H1N1. Other pandemicstrains in human: H7N3 (2 cases reported in Canada), H10N7 (2 casesreported in Egypt) and H5N2 (1 case reported in Japan).

Said influenza virus or antigenic preparation thereof for revaccinationis suitably multivalent such as bivalent or trivalent or quadrivalent orcontain even more influenza strains. Suitably the influenza virus orantigenic preparation thereof for revaccination is trivalent orquadrivalent, having an antigen from three different influenza strains,at least one strain being associated with a pandemic or having thepotential to be associated with a pandemic outbreak. Suitably therevaccination composition comprises a pandemic strain, which may be avariant of the pandemic strain present in the composition for the firstvaccination, and three other strains, typically the classicalcirculating strains.

Alternatively a suitable pre-pandemic vaccine strategy entails periodic(such as every 1-2 years) immunization with influenza strains withpandemic potential with the goal of maintaining and broadening responsesto these viruses over time. While waiting for the optimally matched andregulatory-approved H5N1 pandemic vaccine, pre-pandemic strategy ofvaccination is carried out with an adjuvanted vaccine produced with anH5 strain that is antigenically distinct or from a different clade fromthe pandemic one will prime people before the spread of the pandemicstrain and improve their protection at the time of vaccination with theH5N1 pandemic vaccine. Accordingly in one embodiment, the firstvaccination is made with the claimed adjuvanted monovalent vaccinecomprising one pandemic strain such as H5N1 in one year, followed by anadjuvanted composition comprising a different pandemic influenza strainsuch as for example a H5N1 strain from a different clade or H9N2 at thenext time point (e.g. after 6 months, one year, or two years), thenfollowed by vaccination with an adjuvanted composition comprising stillanother pandemic influenza strain such as H7N7 for example, and soforth. Since it is impossible to predict a) the timing of a potentialpandemic and b) the specific pandemic strain, this strategy relying onthe claimed adjuvanted composition will provide increased insurance formaximizing magnitude and breadth of protective immune responses at theright time. In these strategies the adjuvant is suitably as definedherein.

The features of an influenza virus strain that give it the potential tocause a pandemic or an outbreak of influenza disease associated withpandemic influenza strains are: it contains a new haemagglutinincompared to the haemagglutinin in the currently circulating strains andtherefore nearly all people are immunologically naive; it is capable ofbeing transmitted horizontally in the human population; and it ispathogenic for humans. A new haemagglutinin may be one which has notbeen evident in the human population for an extended period of time,probably a number of decades, such as H2. Or it may be a haemagglutininthat has not been circulating in the human population before, forexample H5, H9, H7 or H6 which are found in avian species (birds). Ineither case the majority, or at least a large proportion of, or even theentire population has not previously encountered the antigen and isimmunologically naïve to it. At present, the influenza A virus that hasbeen identified by the WHO as one that potentially could cause apandemic in humans is the highly pathogenic H5N1 avian influenza virus.Therefore, the pandemic vaccine according to the invention will suitablycomprise H5N1 virus. Two other suitable strains for inclusion into theclaimed composition are H9N2 or H7N1.

Certain parties are generally at an increased risk of becoming infectedwith influenza in a pandemic situation. The elderly, the chronically illand small children are particularly susceptible but many young adultsand apparently healthy people are also at risk. For H2 influenza, thepart of the population born after 1968 is at an increased risk. It isimportant for these groups to be protected effectively as soon aspossible and in a simple way.

Another group of people who are at increased risk are travelers. Peopletravel more today than ever before and the regions where most newviruses emerge, China and South East Asia, have become popular traveldestinations in recent years. This change in travel patterns enables newviruses to reach around the globe in a matter of weeks rather thanmonths or years.

Thus for these groups of people there is a particular need forvaccination to protect against influenza in a pandemic situation or apotential pandemic situation. Suitable pandemic strains are, but notlimited to: H5N1, H9N2, H7N7, H7N1, H2N2 and H1N1. Others pandemicstrains in human: H7N3 (2 cases reported in Canada), H10N7 (2 casesreported in Egypt) and H5N2 (1 case reported in Japan).

Oil-in-Water Emulsion Adjuvant

The adjuvant composition of the invention contains an oil-in-wateremulsion adjuvant, suitably said emulsion comprises a metabolisable oilin an amount of 0.5% to 20% of the total volume, and having oil dropletsof which at least 70% by intensity have diameters of less than 1 μm.

In order for any oil in water composition to be suitable for humanadministration, the oil phase of the emulsion system has to comprise ametabolisable oil. The meaning of the term metabolisable oil is wellknown in the art. Metabolisable can be defined as ‘being capable ofbeing transformed by metabolism’ (Dorland's Illustrated MedicalDictionary, W.B. Sanders Company, 25th edition (1974)). The oil may beany vegetable oil, fish oil, animal oil or synthetic oil, which is nottoxic to the recipient and is capable of being transformed bymetabolism. Nuts, seeds, and grains are common sources of vegetableoils. Synthetic oils are also part of this invention and can includecommercially available oils such as NEOBEE® and others. A particularlysuitable metabolisable oil is squalene. Squalene(2,6,10,15,19,23-Hexamethyl-2,6,10,14,18,22-tetracosahexaene) is anunsaturated oil which is found in large quantities in shark-liver oil,and in lower quantities in olive oil, wheat germ oil, rice bran oil, andyeast, and is a particularly suitable oil for use in this invention.Squalene is a metabolisable oil by virtue of the fact that it is anintermediate in the biosynthesis of cholesterol (Merck index, 10thEdition, entry no. 8619).

Oil in water emulsions per se are well known in the art, and have beensuggested to be useful as adjuvant compositions (EP 399843; WO95/17210).

Suitably the metabolisable oil is present in an amount of 0.5% to 20%(final concentration) of the total volume of the immunogeniccomposition, suitably an amount of 1.0% to 10% of the total volume,suitably in an amount of 2.0% to 6.0% of the total volume.

In a specific embodiment, the metabolisable oil is present in a finalamount of about 0.5%, 1%, 3.5% or 5% of the total volume of theimmunogenic composition. In another specific embodiment, themetabolisable oil is present in a final amount of 0.5%, 1%, 3.57% or 5%of the total volume of the immunogenic composition. A suitable amount ofsqualene is about 10.7 mg per vaccine dose, suitably from 10.4 to 11.0mg per vaccine dose.

Suitably the oil-in-water emulsion systems of the present invention havea small oil droplet size in the sub-micron range. Suitably the dropletsizes will be in the range 120 to 750 nm, suitably sizes from 120 to 600nm in diameter. Typically the oil-in water emulsion contains oildroplets of which at least 70% by intensity are less than 500 nm indiameter, in particular at least 80% by intensity are less than 300 nmin diameter, suitably at least 90% by intensity are in the range of 120to 200 nm in diameter.

The oil droplet size, i.e., diameter, according to the present inventionis given by intensity. There are several ways of determining thediameter of the oil droplet size by intensity. Intensity is measured byuse of a sizing instrument, suitably by dynamic light scattering such asthe Malvern Zetasizer 4000 or suitably the Malvern Zetasizer 3000HS. Adetailed procedure is given in Example 11.2. A first possibility is todetermine the z average diameter ZAD by dynamic light scattering(PCS-Photon correlation spectroscopy); this method additionally give thepolydispersity index (PDI), and both the ZAD and PDI are calculated withthe cumulants algorithm. These values do not require the knowledge ofthe particle refractive index. A second mean is to calculate thediameter of the oil droplet by determining the whole particle sizedistribution by another algorithm, either the Contin, or NNLS, or theautomatic “Malvern” one (the default algorithm provided for by thesizing instrument). Most of the time, as the particle refractive indexof a complex composition is unknown, only the intensity distribution istaken into consideration, and if necessary the intensity meanoriginating from this distribution.

The oil in water emulsion according to the invention comprises a steroland/or a tocol such as tocopherol, in particular alpha tocopherol.Sterols are well known in the art, for example cholesterol is well knownand is, for example, disclosed in the Merck Index, 11th Edn., page 341,as a naturally occurring sterol found in animal fat. Other suitablesterols include β-sitosterol, stigmasterol, ergosterol andergocalciferol. Said sterol is suitably present in an amount of 0.01% to20% (w/v) of the total volume of the immunogenic composition, suitablyat an amount of 0.1% to 5% (w/v). Suitably, when the sterol ischolesterol, it is present in an amount of between 0.02% and 0.2% (w/v)of the total volume of the immunogenic composition, typically at anamount of 0.02% (w/v) in a 0.5 ml vaccine dose volume, or 0.07% (w/v) in0.5 ml vaccine dose volume or 0.1% (w/v) in 0.7 ml vaccine dose volume.

Tocols (e.g. vitamin E) are also often used in oil emulsions adjuvants(EP 0 382 271 B1; U.S. Pat. No. 5,667,784; WO 95/17210). Tocols used inthe oil emulsions (optionally oil in water emulsions) of the inventionmay be formulated as described in EP 0 382 271 B1, in that the tocolsmay be dispersions of tocol droplets, optionally comprising anemulsifier, of optionally less than 1 micron in diameter. Alternatively,the tocols may be used in combination with another oil, to form the oilphase of an oil emulsion. Examples of oil emulsions which may be used incombination with the tocol are described herein, such as themetabolisable oils described above.

Suitably alpha-tocopherol or a derivative thereof such asalpha-tocopherol succinate is present. Suitably alpha-tocopherol ispresent in an amount of between 0.2% and 5.0% (v/v) of the total volumeof the immunogenic composition, suitably at an amount of 2.5% (v/v) in a0.5 ml vaccine dose volume, or 0.5% (v/v) in 0.5 ml vaccine dose volumeor 1.7-1.9% (v/v), suitably 1.8% in 0.7 ml vaccine dose volume. By wayof clarification, concentrations given in v/v can be converted intoconcentration in w/v by applying the following conversion factor: a 5%(v/v) alpha-tocopherol concentration is equivalent to a 4.8% (w/v)alpha-tocopherol concentration. A suitable amount of alpha-tocopherol isabout 11.9 mg per vaccine dose, suitably from 11.6 to 12.2 mg pervaccine dose.

The oil in water emulsion comprises an emulsifying agent. Theemulsifying agent may be present at an amount of 0.01 to 5.0% by weightof the immunogenic composition (w/w), suitably present at an amount of0.1 to 2.0% by weight (w/w). Suitable concentration are 0.5 to 1.5% byweight (w/w) of the total composition.

The emulsifying agent may suitably be polyoxyethylene sorbitanmonooleate (TWEEN™ (known as “Tween-ether” splitting) 80). In a specificembodiment, a 0.5 ml vaccine dose volume contains 1% (w/w) TWEEN™ (knownas “Tween-ether” splitting) 80, and a 0.7 ml vaccine dose volumecontains 0.7% (w/w) TWEEN™ (known as “Tween-ether” splitting) 80. Inanother specific embodiment the concentration of TWEEN™ (known as“Tween-ether” splitting) 80 is 0.2% (w/w). A suitable amount ofpolysorbate 80 is about 4.9 mg per vaccine dose, suitably from 4.6 to5.2 mg per vaccine dose.

Suitably a vaccine dose comprises alpha-tocopherol in an amount of about11.9 mg per vaccine dose, squalene in an amount of 10.7 mg per vaccinedose, and polysorbate 80 in an amount of about 4.9 mg per vaccine dose.

The oil in water emulsion adjuvant may be utilised with other adjuvantsor immuno-stimulants and therefore an important embodiment of theinvention is an oil in water formulation comprising squalene or anothermetabolisable oil, a tocopherol, such as alpha tocopherol, and TWEEN™(known as “Tween-ether” splitting) 80. The oil in water emulsion mayalso contain span 85 and/or Lecithin. Typically the oil in water willcomprise from 2 to 10% squalene of the total volume of the immunogeniccomposition, from 2 to 10% alpha tocopherol and from 0.3 to 3% TWEEN™(known as “Tween-ether” splitting) 80, and may be produced according tothe procedure described in WO 95/17210. Suitably the ratio ofsqualene:alpha tocopherol is equal or less than 1 as this provides amore stable emulsion. Span 85 (polyoxyethylene sorbitan trioleate) mayalso be present, for example at a level of 1%.

Immunogenic Properties of the Immunogenic Composition Used for the FirstVaccination of the Present Invention

In the present invention the monovalent influenza composition is capableof inducing an improved CD4 T-cell immune response against at least oneof the component antigen(s) or antigenic composition compared to the CD4T-cell immune response obtained with the corresponding composition whichin un-adjuvanted, i.e., does not contain any exogeneous adjuvant (hereinalso referred to as ‘plain composition’). In a specific embodiment, saidimproved CD4 T-cell immune response is against the pandemic influenzastrain.

By ‘improved CD4 T-cell immune response is meant that a higher CD4response is obtained in a human patient after administration of theadjuvanted immunogenic composition than that obtained afteradministration of the same composition without adjuvant. For example, ahigher CD4 T-cell response is obtained in a human patient uponadministration of an immunogenic composition comprising an influenzavirus or antigenic preparation thereof together with an oil-in-wateremulsion adjuvant comprising a metabolisable oil, a tocopherol, such asalpha tocopherol, and an emulsifying agent, compared to the responseinduced after administration of an immunogenic composition comprising aninfluenza virus or antigenic preparation thereof which is un-adjuvanted.Such formulation will advantageously be used to induce anti-influenzaCD4-T cell response capable of detection of influenza epitopes presentedby MHC class II molecules.

Suitably said immunological response induced by an adjuvanted splitinfluenza composition for use in the present invention is higher thanthe immunological response induced by any other un-adjuvanted influenzaconventional vaccine, such as sub-unit influenza vaccine or wholeinfluenza virus vaccine.

In particular but not exclusively, said ‘improved CD4 T-cell immuneresponse’ is obtained in an immunologically unprimed patient, i.e., apatient who is seronegative to said influenza virus or antigen. Thisseronegativity may be the result of said patient having never faced suchvirus or antigen (so-called ‘naive’ patient) or, alternatively, havingfailed to respond to said antigen once encountered. Suitably saidimproved CD4 T-cell immune response is obtained in an immunocompromisedsubject such as an elderly, typically at least 50 years of age,typically 65 years of age or above, or an adult below 65 years of agewith a high risk medical condition (‘high risk’ adult), or a child underthe age of two.

The improved CD4 T-cell immune response may be assessed by measuring thenumber of cells producing any of the following cytokines:

-   -   cells producing at least two different cytokines (CD40L, IL-2,        IFNγ, TNFα)    -   cells producing at least CD40L and another cytokine (IL-2, TNFα,        IFNγ)    -   cells producing at least IL-2 and another cytokine (CD40L, TNFα,        IFNγ)    -   cells producing at least IFNγ and another cytokine (IL-2, TNFα,        CD40L)    -   cells producing at least TNFα and another cytokine (IL-2, CD40L,        IFNγ)

There will be improved CD4 T-cell immune response when cells producingany of the above cytokines will be in a higher amount followingadministration of the adjuvanted composition compared to theadministration of the un-adjuvanted composition. Typically at least one,suitably two of the five conditions mentioned herein above will befulfilled. In a particular embodiment, the cells producing all fourcytokines will be present at a higher amount in the adjuvanted groupcompared to the un-adjuvanted group.

In a specific embodiment, an improved CD4 T-cell immune response may beconferred by the adjuvanted influenza composition of the presentinvention and may be ideally obtained after one single administration.The single dose approach will be extremely relevant for example in arapidly evolving outbreak situation. In certain circumstances,especially for the elderly population, or in the case of young children(below 9 years of age) who are vaccinated for the first time againstinfluenza, or in the case of a pandemics, it may be beneficial toadminister two doses of the same composition for that season. The seconddose of said same composition (still considered as ‘composition forfirst vaccination’) may be administered during the on-going primaryimmune response and is adequately spaced. Typically the second dose ofthe composition is given a few weeks, or about one month, e.g. 2 weeks,3 weeks, 4 weeks, 5 weeks, or 6 weeks after the first dose, to helpprime the immune system in unresponsive or poorly responsiveindividuals. In a specific aspect, the primo-vaccination is followed bya subsequent vaccination course of adjuvanted vaccine product containinga heterologous influenza strain.

In a specific embodiment, the administration of said immunogeniccomposition alternatively or additionally induces an improved B-memorycell response in patients administered with the adjuvanted immunogeniccomposition compared to the B-memory cell response induced inindividuals immunized with the un-adjuvanted composition. An improvedB-memory cell response is intended to mean an increased frequency ofperipheral blood B lymphocytes capable of differentiation intoantibody-secreting plasma cells upon antigen encounter as measured bystimulation of in-vitro differentiation (see Example sections, e.g.methods of Elispot B cells memory).

In a still further specific embodiment, the vaccination with thecomposition for the first vaccination, adjuvanted, has no measurableimpact on the CD8 response.

Suitably, the claimed composition comprising an influenza virus orantigenic preparation thereof formulated with an oil-in-water emulsionadjuvant, in particular an oil-in-water emulsion adjuvant comprising ametabolisable oil, a sterol and/or a tocopherol, such as alphatocopherol, and an emulsifying agent, will be effective in promoting Tcell responses in an immuno-compromised human population. Suitably, theadministration of a single dose of the immunogenic composition for firstvaccination, as described in the invention will be capable of providingbetter sero-protection, as assessed by the correlates of protection forinfluenza vaccines, following revaccination against influenza, than doesthe vaccination with an un-adjuvanted influenza vaccine. The claimedadjuvanted formulation will also induce an improved CD4 T-cell immuneresponse against influenza virus compared to that obtained with theun-adjuvanted formulation. This property can be associated with anincreased responsiveness upon vaccination or infection vis-à-visinfluenza antigenic exposure. Furthermore, this may also be associatedwith a cross-responsiveness, i.e., a higher ability to respond againstvariant influenza strains. This qualitatively and/or quantitativelyimproved response may be beneficial in all populations in the case ofpandemics, and especially in an immuno-compromised human population suchas the elderly population (65 years of age and above) and in particularthe high risk elderly population. This may also be of benefit to theinfant population (below 5 years, suitably below 2 years of age). Thisimproved response will be of benefit for usage for priming e.g. fromstockpiled vaccine containing a drift variant, before or at onset ofpandemic outbreak. This may result in reducing the overall morbidity andmortality rate and preventing emergency admissions to hospital forpneumonia and other influenza-like illness. Furthermore it allowsinducing a CD4 T cell response which is more persistent in time, e.g.still present one year after the first vaccination, compared to theresponse induced with the un-adjuvanted formulation.

Suitably the CD4 T-cell immune response, such as the improved CD4 T-cellimmune response obtained in an unprimed subject, involves the inductionof a cross-reactive CD4 T helper response. In particular, the amount ofcross-reactive CD4 T cells is increased. By ‘cross-reactive’ CD4response is meant CD4 T-cell targeting shared epitopes between influenzastrains.

Usually, available influenza vaccines are effective only againstinfecting strains of influenza virus that have haemagglutinin of similarantigenic characteristics. When the infecting (circulating) influenzavirus has undergone minor changes (such as a point mutation or anaccumulation of point mutations resulting in amino acid changes in thefor example) in the surface glycoproteins in particular haemagglutinin(antigenic drift variant virus strain) the vaccine may still providesome protection, although it may only provide limited protection as thenewly created variants may escape immunity induced by prior influenzainfection or vaccination. Antigenic drift is responsible for annualepidemics that occur during interpandemic periods (Wiley & Skehel, 1987,Ann. Rev. Biochem. 56, 365-394). The induction of cross-reactive CD4 Tcells provides an additional advantage to the composition of theinvention, in that it may provide also cross-protection, in other wordsprotection against heterologous infections, i.e., infections caused by acirculating influenza strain which is a variant (e.g. a drift) of theinfluenza strain contained in the immunogenic composition. This may beadvantageous when the circulating strain is difficult to propagate ineggs or to produce in cell culture, rendering the use of a driftedstrain a working alternative. This may also be advantageous when thesubject received a first and a second vaccination several months or ayear apart, and the influenza strain in the immunogenic composition usedfor a second immunization is a drift variant strain of the strain usedin the composition used for the first vaccination.

The adjuvanted influenza immunogenic composition as herein defined hastherefore a higher ability to induce sero-protection and cross-reactiveCD4 T cells in vaccinated elderly subjects. This characteristic may beassociated with a higher ability to respond against a variant strain ofthe strain present in the immunogenic composition. This may prove to bean important advantage in a pandemic situation. For example a monovalentinfluenza immunogenic composition comprising any of H5, a H2, a H9, H7or H6 strain(s) may provide a higher ability to respond against apandemic variant, i.e., a drift strain of said pandemic strain(s),either upon subsequent vaccination with or upon infection by said driftstrain.

Detection of Cross-Reactive CD4 T-Cells Following Vaccination withInfluenza Vaccine

Following classical trivalent Influenza vaccine administration (3weeks), there is a substantial increase in the frequency of peripheralblood CD4 T-cells responding to antigenic strain preparation (wholevirus or split antigen) that is homologous to the one present in thevaccine (H3N2: A/Panama/2007/99, H1N1: A/New Caledonia/20/99, B:B/Shangdong/7/97) (see Example III). A comparable increase in frequencycan be seen if peripheral blood CD4 T-cells are restimulated withinfluenza strains classified as drifted strains (H3N2: A/Sydney/5/97,H1N1: A/Beijing/262/95, B: B/Yamanashi/166/98).

In contrast, if peripheral blood CD4 T-cells are restimulated withinfluenza strains classified as shift strains (H2N2: A/Singapore/1/57,H9N2: A/Hongkong/1073/99) by expert in the field, there is no observableincrease following vaccination.

CD4 T-cells that are able to recognize both homologous and driftedInfluenza strains have been named in the present document“cross-reactive”. The adjuvanted influenza compositions as describedherein have been capable to show heterosubtypic cross-reactivity sincethere is observable cross-reactivity against drifted Influenza strains.As said above, the ability of a pandemic vaccine formulation to beeffective against drift pandemic strains may prove to be an importantcharacteristic in the case of pandemics.

Consistently with the above observations, CD4 T-cell epitopes shared bydifferent Influenza strains have been identified in human (Gelder C etal. 1998, Int Immunol. 10(2):211-22; Gelder C M et al. 1996 J Virol.70(7):4787-90; Gelder C M et al. 1995 J Virol. 1995 69(12): 7497-506).

Due to its immunogenic properties, the claimed composition will be ableto establish a proactive vaccination strategy against the threat of ahuman influenza pandemic, including the stockpiling of pre-pandemicvaccine in order to better prepare against the onset of a pandemic.

Specifically, the pre-pandemic vaccine is one that has been produced,for example through to use of reverse genetics, using a strain of H5N1(avian flu) similar to the ones currently circulating in the birdpopulation. The immunity developed in response to the pre-pandemicvaccine will allow the immune system to be ‘primed’ or ‘educated’ inreadiness and thereby allowing for more rapid development of protectiveimmune responses after encountering the actual pandemic virus strainleading to a decreased susceptibility to a related pandemic strain ofthe influenza. Once a pandemic has been declared by WHO and the finalpandemic strain identified (be it a drift strain), the pre-pandemicvaccine will also allow a more rapid immune response to the pandemicvaccine when the latter becomes available.

In a specific embodiment, the adjuvanted composition may offer theadditional benefit of providing better protection against circulatingstrains which have undergone a major change (such as gene recombinationfor example, between two different species) in the haemagglutinin(antigenic shift) against which currently available vaccines have noefficacy.

Other Adjuvants

The composition may comprise an additional adjuvant, in particular aTRL-4 ligand adjuvant, suitably a non-toxic derivative of lipid A. Asuitable TRL-4 ligand is 3 de-O-acylated monophosphoryl lipid A(3D-MPL). Other suitable TLR-4 ligands are lipopolysaccharide (LPS) andderivatives, MDP (muramyl dipeptide) and F protein of RSV.

In one embodiment the composition may additionally include a Toll likereceptor (TLR) 4 ligand, such as a non-toxic derivative of lipid A,particularly monophosphoryl lipid A or more particularly 3-Deacylatedmonophoshoryl lipid A (3D-MPL).

3D-MPL is sold under the trademark MPL® by Corixa corporation now GSK(herein MPL) and primarily promotes CD4+ T cell responses with an IFN-γ(Th1) phenotype. It can be produced according to the methods disclosedin GB 2 220 211 A. Chemically it is a mixture of 3-deacylatedmonophosphoryl lipid A with 3, 4, 5 or 6 acylated chains. In particular,in the compositions of the present invention small particle 3 D-MPL isused. Small particle 3D-MPL has a particle size such that it may besterile-filtered through a 0.22 μm filter. Such preparations aredescribed in WO94/21292 and in Example II.

3D-MPL can be used, for example, at an amount of 1 to 100 μg (w/v) percomposition dose, suitably in an amount of 10 to 50 μg (w/v) percomposition dose. A suitable amount of 3D-MPL is for example any of 1,2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21,22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39,40, 41, 42, 43, 44, 45, 46, 47, 48, 49, or 50 μg (w/v) per compositiondose. Suitably, 3D-MPL amount ranges from 25 to 75 μg (w/v) percomposition dose. Usually a composition dose will be ranging from about0.5 ml to about 1 ml. A typical vaccine dose are 0.5 ml, 0.6 ml, 0.7 ml,0.8 ml, 0.9 ml or 1 ml. In a suitable embodiment, a final concentrationof 50 μg of 3D-MPL is contained per ml of vaccine composition, or 25 μgper 0.5 ml vaccine dose. In other suitable embodiments, a finalconcentration of 35.7 μg or 71.4 μg of 3D-MPL is contained per ml ofvaccine composition. Specifically, a 0.5 ml vaccine dose volume contains25 μg or 50 μg of 3D-MPL per dose.

The dose of MPL is suitably able to enhance an immune response to anantigen in a human. In particular a suitable MPL amount is that whichimproves the immunological potential of the composition compared to theunadjuvanted composition, or compared to the composition adjuvanted withanother MPL amount, whilst being acceptable from a reactogenicityprofile.

Synthetic derivatives of lipid A are known, some being described asTLR-4 agonists, and include, but are not limited to:

-   OM 174    (2-deoxy-6-o-[2-deoxy-2-[(R)-3-dodecanoyloxytetra-decanoylamino]-4-o-phosphono-β-D-glucopyranosyl]-2-[(R)-3-hydroxytetradecanoylamino]-α-D-glucopyranosyldihydrogenphosphate),    (WO 95/14026)-   OM 294 DP    (3S,9R)-3-[(R)-dodecanoyloxytetradecanoylamino]-4-oxo-5-aza-9(R)-[(R)-3-hydroxytetradecanoylamino]decan-1,10-diol,1,10-bis(dihydrogenophosphate)    (WO99/64301 and WO 00/0462)-   OM 197 MP-Ac DP    (3S-,9R)-3-[(R)-dodecanoyloxytetradecanoylamino]-4-oxo-5-aza-9-[(R)-3-hydroxytetradecanoylamino]decan-1,10-diol,1-dihydrogenophosphate    10-(6-aminohexanoate) (WO 01/46127)

Other suitable TLR-4 ligands are, for example, lipopolysaccharide andits derivatives, muramyl dipeptide (MDP) or F protein of respiratorysyncitial virus.

Another suitable immunostimulant for use in the present invention isQuil A and its derivatives. Quil A is a saponin preparation isolatedfrom the South American tree Quilaja saponaria Molina and was firstdescribed by Dalsgaard et al. in 1974 (“Saponin adjuvants”, Archiv. fürdie gesamte Virusforschung, Vol. 44, Springer Verlag, Berlin, p 243-254)to have adjuvant activity. Purified fragments of Quil A have beenisolated by HPLC which retain adjuvant activity without the toxicityassociated with Quil A (EP 0 362 278), for example QS7 and QS21 (alsoknown as QA7 and QA21). QS-21 is a natural saponin derived from the barkof Quillaja saponaria Molina, which induces CD8+ cytotoxic T cells(CTLs), Th1 cells and a predominant IgG2a antibody response and is asuitable saponin in the context of the present invention.

Particular formulations of QS21 have been described which areparticularly suitable, these formulations further comprise a sterol(WO96/33739). The saponins forming part of the present invention may bein the form of an oil in water emulsion (WO 95/17210).

Revaccination and Composition Used for Revaccination (BoostingComposition)

An aspect of the present invention provides the use of an influenzaantigen in the manufacture of an influenza immunogenic composition forrevaccination of humans previously vaccinated with a monovalentinfluenza composition as claimed herein or with said monovalentinfluenza composition comprising a variant influenza strain, formulatedwith an oil-in-water emulsion adjuvant as herein defined.

Typically revaccination is made at least 1 month, suitably at least twomonths, suitably at least three months, or 4 months after the firstvaccination, suitably 8 to 14 months after, suitably at around 10 to 12months after or even longer. Suitably revaccination is made at least 6months after the first vaccination(s), suitably 8 to 14 months after,suitably at around 10 to 12 months after.

The immunogenic composition for revaccination (the boosting composition)may contain any type of antigen preparation, either inactivated,recombinant or live attenuated. It may contain the same type of antigenpreparation i.e., split influenza virus or split influenza virusantigenic preparation thereof, a whole virion, a purified HA and NA(sub-unit) vaccine or a virosome, as the immunogenic composition usedfor the first vaccination. Alternatively the boosting composition maycontain another type of influenza antigen, i.e., split influenza virusor split influenza virus antigenic preparation thereof, a whole virion,a purified HA and NA (sub-unit) vaccine or a virosome, than that usedfor the first vaccination. Suitably a split virus or a whole virionvaccine is used.

Accordingly, in one embodiment, the invention provides for the use of aninfluenza virus or antigenic preparation thereof in the manufacture ofan immunogenic composition for revaccination of humans previouslyvaccinated with a monovalent pandemic immunogenic composition as claimedherein.

The boosting composition may be adjuvanted or un-adjuvanted. In oneembodiment the composition for revaccination is not adjuvanted and is aclassical influenza vaccine containing three inactivated split virionantigens prepared from the WHO recommended strains of the appropriateinfluenza season, such as FLUARIX™/α-RIX®/INFLUSPLIT® or FLULAVAL™ givenintramuscularly.

In another embodiment the composition for revaccination is adjuvanted.Suitably the boosting composition comprises an oil-in-water emulsionadjuvant, in particular an oil-in-water emulsion adjuvant comprising ametabolisable oil, a sterol and/or a tocopherol, such as alphatocopherol, and an emulsifying agent. Specifically, said oil-in-wateremulsion adjuvant comprises at least one metabolisable oil in an amountof 0.5% to 20% of the total volume, and has oil droplets of which atleast 70% by intensity have diameters of less than 1 μm. Alternativelythe boosting composition comprises an alum adjuvant, either aluminiumhydroxide or aluminium phosphate or a mixture of both.

In one embodiment, the first vaccination is made with a pandemicinfluenza composition as herein defined, suitably a split influenzacomposition, and the revaccination is made as follows.

In a specific embodiment, the immunogenic composition for revaccinationcontains an influenza virus or antigenic preparation thereof whichshares common CD4 T-cell epitopes with the influenza virus or antigenicpreparation thereof used for the first vaccination. A common CD4 T cellepitope is intended to mean peptides/sequences/epitopes from differentantigens which can be recognised by the same CD4 cell (see examples ofdescribed epitopes in: Gelder C et al. 1998, Int Immunol. 10(2):211-22;Gelder C M et al. 1996 J Virol. 70(7):4787-90; Gelder C M et al. 1995 JVirol. 1995 69(12):7497-506).

In an embodiment according to the invention, the boosting composition isa monovalent influenza composition comprising an influenza strain whichis associated with a pandemic or has the potential to be associated witha pandemic. Suitable strains are, but not limited to: H5N1, H9N2, H7N7,H2N2, H7N1 and H1N1. Said strain may be the same as that, or one ofthose, present in the composition used for the first vaccination. In analternative embodiment said strain may be a variant strain, i.e., adrift strain, of the strain present in the composition used for thefirst vaccination.

In another specific embodiment, the composition for revaccination is amultivalent influenza vaccine. In particular, when the boostingcomposition is a multivalent vaccine such as a bivalent, trivalent orquadrivalent vaccine, at least one strain is associated with a pandemicor has the potential to be associated with a pandemic. In a specificembodiment, two or more strains in the boosting composition are pandemicstrains. In another specific embodiment, the at least one pandemicstrain in the boosting composition is of the same type as that, or oneof those, present in the composition used for the first vaccination. Inan alternative embodiment the at least one strain may be a variantstrain, i.e., a drift strain, of the at least one pandemic strainpresent in the composition used for the first vaccination.

Accordingly, in another aspect of the present invention, there isprovided the use of an influenza virus or antigenic preparation thereof,from a first pandemic influenza strain, in the manufacture of animmunogenic composition as herein defined, for protection againstinfluenza infections caused by a influenza strain which is a variant ofsaid first influenza strain.

Accordingly, in another aspect of the present invention, there isprovided the use of:

-   -   (a) an influenza virus or antigenic preparation thereof, from a        first influenza strain, and    -   (b) an oil-in-water emulsion adjuvant as herein defined        in the manufacture of an immunogenic composition as herein        defined, for protection against influenza infections caused by a        influenza strain which is a variant of said first influenza        strain.

The composition for revaccination may be adjuvanted or not.

Typically a boosting composition, where used, is given at the nextinfluenza season, e.g. approximately one year after the firstimmunogenic composition. The boosting composition may also be givenevery subsequent year (third, fourth, fifth vaccination and so forth).The boosting composition may be the same as the composition used for thefirst vaccination. Suitably, the boosting composition contains aninfluenza virus or antigenic preparation thereof which is a variantstrain of the influenza virus used for the first vaccination. Inparticular, the influenza viral strains or antigenic preparation thereofare selected according to the reference material distributed by theWorld Health Organisation such that they are adapted to the influenzastrain which is circulating on the year of the revaccination. Suitablythe first vaccination is made at the declaration of a pandemic andrevaccination is made later. Suitably, the revaccination is made with avaccine comprising an influenza strain (e.g. H5N1 Vietnam) which is ofthe same subtype as that used for the first vaccination (e.g. H5N1Vietnam). In a specific embodiment, the revaccination is made with adrift strain of the same sub-type, e.g. H5N1 Indonesia. In anotherembodiment, said influenza strain used for the revaccination is a shiftstrain, i.e., is different from that used for the first vaccination,e.g. it has a different HA or NA subtype, such as H5N2 (same HA subtypeas H5N1 but different NA subtype) or H7N1 (different HA subtype fromH5N1 but same NA subtype).

The influenza antigen or antigenic composition used in revaccinationsuitably comprises an adjuvant or an oil-in-water emulsion, suitably asdescribed above. The adjuvant may be an oil-in-water emulsion adjuvantas herein above described, which is suitable, optionally containing anadditional adjuvant such as TLR-4 ligand such as 3D-MPL or a saponin, ormay be another suitable adjuvant such as alum or alum alternatives suchas polyphosphazene for example.

Suitably revaccination induces any, suitably two or all, of thefollowing: (i) an improved CD4 response against the influenza virus orantigenic preparation thereof, or (ii) an improved B cell memoryresponse or (iii) an improved humoral response, compared to theequivalent response induced after a first vaccination with theun-adjuvanted influenza virus or antigenic preparation thereof. Suitablythe immunological responses induced after revaccination with theadjuvanted influenza virus or antigenic preparation thereof as hereindefined, are higher than the corresponding response induced after therevaccination with the un-adjuvanted composition. Suitably theimmunological responses induced after revaccination with anun-adjuvanted, suitably split, influenza virus are higher in thepopulation first vaccinated with the adjuvanted, suitably split,influenza composition than the corresponding response in the populationfirst vaccinated with the un-adjuvanted, suitably split, influenzacomposition.

In one aspect according to the invention, the revaccination of thesubjects with a boosting composition comprising an influenza virus andan oil-in-water emulsion adjuvant comprising a metabolisable oil, asterol and/or a tocopherol, such as alpha tocopherol, and an emulsifyingagent, as defined herein above, will show higher antibody titers thanthe corresponding values in the group of people first vaccinated withthe un-adjuvanted composition and boosted with the un-adjuvantedcomposition. The effect of the adjuvant in enhancing the antibodyresponse to revaccination is especially of importance in the elderlypopulation which is known to have a low response to vaccination orinfection by influenza virus. In particular, the adjuvantedcomposition-associated benefit will also be marked in terms of improvingthe CD4 T-cell response following revaccination.

The adjuvanted composition of the invention will be capable of inducinga better cross-responsiveness against drifted strain (the influenzastrain from the next influenza season) compared to the protectionconferred by the control vaccine. Said cross-responsiveness has shown ahigher persistence compared to that obtained with the un-adjuvantedformulation. The effect of the adjuvant in enhancing thecross-responsiveness against drifted strain is of important in apandemic situation.

In a further embodiment the invention relates to a vaccination regime inwhich the first vaccination is made with an influenza composition,suitably a split influenza composition, containing an influenza strainthat could potentially cause a pandemic and the revaccination is madewith a composition, either monovalent or multivalent, comprising atleast one circulating strain, either a pandemic strain or a classicalstrain.

CD4 Epitope in HA

This antigenic drift mainly resides in epitope regions of the viralsurface proteins haemagglutinin (HA) and neuraminidase (NA). It is knownthat any difference in CD4 and B cell epitopes between differentinfluenza strains, being used by the virus to evade the adaptiveresponse of the host immune system, will play a major role in influenzavaccination.

CD4 T-cell epitopes shared by different Influenza strains have beenidentified in human (see for example: Gelder C et al. 1998, Int Immunol.10(2):211-22; Gelder C M et al. 1996 J Virol. 70(7):4787-90; and GelderC M et al. 1995 J Virol. 1995 69(12):7497-506).

In a specific embodiment, the revaccination is made by using a boostingcomposition which contains an influenza virus or antigenic preparationthereof which shares common CD4 T-cell epitopes with the influenza virusantigen or antigenic preparation thereof used for the first vaccination.The invention thus relates to the use of the immunogenic compositioncomprising a pandemic influenza virus or antigenic preparation thereofand an oil-in-water emulsion adjuvant, in particular an oil-in-wateremulsion adjuvant comprising a metabolisable oil, a sterol and/or atocopherol, such as alpha tocopherol, and an emulsifying agent, in themanufacture of a first vaccination-component of a multi-dose vaccine,the multi-dose vaccine further comprising, as a boosting dose, aninfluenza virus or antigenic preparation thereof which shares common CD4T-cell epitopes with the pandemic influenza virus antigen or virusantigenic preparation thereof of the dose given at the firstvaccination.

Vaccination Means

The composition of the invention may be administered by any suitabledelivery route, such as intradermal, mucosal e.g. intranasal, oral,intramuscular or subcutaneous. Other delivery routes are well known inthe art.

The intramuscular delivery route is particularly suitable for theadjuvanted influenza composition. The composition according to theinvention may be presented in a monodose container, or alternatively, amultidose container, particularly suitable for a pandemic vaccine. Inthis instance an antimicrobial preservative such a thiomersal istypically present to prevent contamination during use. Thiomersalconcentration may be at 25 μg/0.5 ml dose (i.e., 50 μg/mL). A thiomersalconcentration of 5 μg/0.5 ml dose (i.e., 10 μg/ml) or 10 μg/0.5 ml dose(i.e., 20 μg/ml) is suitably present. A suitable IM delivery devicecould be used such as a needle-free liquid jet injection device, forexample the Biojector® 2000 (Bioject, Portland, Oreg.). Alternatively apen-injector device, such as is used for at-home delivery ofepinephrine, could be used to allow self administration of vaccine. Theuse of such delivery devices may be particularly amenable to large scaleimmunization campaigns such as would be required during a pandemic.

Intradermal delivery is another suitable route. Any suitable device maybe used for intradermal delivery, for example short needle devices suchas those described in U.S. Pat. Nos. 4,886,499, 5,190,521, 5,328,483,5,527,288, 4,270,537, 5,015,235, 5,141,496, 5,417,662. Intradermalvaccines may also be administered by devices which limit the effectivepenetration length of a needle into the skin, such as those described inWO99/34850 and EP1092444, incorporated herein by reference, andfunctional equivalents thereof. Also suitable are jet injection deviceswhich deliver liquid vaccines to the dermis via a liquid jet injector orvia a needle which pierces the stratum corneum and produces a jet whichreaches the dermis. Jet injection devices are described for example inU.S. Pat. Nos. 5,480,381, 5,599,302, 5,334,144, 5,993,412, 5,649,912,5,569,189, 5,704,911, 5,383,851, 5,893,397, 5,466,220, 5,339,163,5,312,335, 5,503,627, 5,064,413, 5,520,639, 4,596,556, 4,790,824,4,941,880, 4,940,460, WO 97/37705 and WO 97/13537. Also suitable areballistic powder/particle delivery devices which use compressed gas toaccelerate vaccine in powder form through the outer layers of the skinto the dermis. Additionally, conventional syringes may be used in theclassical mantoux method of intradermal administration.

Another suitable administration route is the subcutaneous route. Anysuitable device may be used for subcutaneous delivery, for exampleclassical needle. Suitably, a needle-free jet injector service is used,such as that published in WO 01/05453, WO 01/05452, WO 01/05451, WO01/32243, WO 01/41840, WO 01/41839, WO 01/47585, WO 01/56637, WO01/58512, WO 01/64269, WO 01/78810, WO 01/91835, WO 01/97884, WO02/09796, WO 02/34317. Suitably said device is pre-filled with theliquid vaccine formulation.

Alternatively the vaccine is administered intranasally. Typically, thevaccine is administered locally to the nasopharyngeal area, suitablywithout being inhaled into the lungs. It is desirable to use anintranasal delivery device which delivers the vaccine formulation to thenasopharyngeal area, without or substantially without it entering thelungs.

Suitable devices for intranasal administration of the vaccines accordingto the invention are spray devices. Suitable commercially availablenasal spray devices include BD ACCUSPRAY SCF™ (nasal spray system).Nebulisers produce a very fine spray which can be easily inhaled intothe lungs and therefore does not efficiently reach the nasal mucosa.Nebulisers are therefore not preferred.

Suitable spray devices for intranasal use are devices for which theperformance of the device is not dependent upon the pressure applied bythe user. These devices are known as pressure threshold devices. Liquidis released from the nozzle only when a threshold pressure is applied.These devices make it easier to achieve a spray with a regular dropletsize. Pressure threshold devices suitable for use with the presentinvention are known in the art and are described for example in WO91/13281 and EP 311 863 B and EP 516 636, incorporated herein byreference. Such devices are commercially available from Pfeiffer GmbHand are also described in Bommer, R. Pharmaceutical Technology Europe,September 1999.

Suitable intranasal devices produce droplets (measured using water asthe liquid) in the range 1 to 200 μm, suitably 10 to 120 μm. Below 10 μmthere is a risk of inhalation, therefore it is desirable to have no morethan about 5% of droplets below 10 μm. Droplets above 120 μm do notspread as well as smaller droplets, so it is desirable to have no morethan about 5% of droplets exceeding 120 μm.

Bi-dose delivery is a further suitable feature of an intranasal deliverysystem for use with the vaccines according to the invention. Bi-dosedevices contain two sub-doses of a single vaccine dose, one sub-dose foradministration to each nostril. Generally, the two sub-doses are presentin a single chamber and the construction of the device allows theefficient delivery of a single sub-dose at a time. Alternatively, amonodose device may be used for administering the vaccines according tothe invention.

Alternatively, the epidermal or transdermal vaccination route is alsocontemplated in the present invention.

In one aspect of the present invention, the adjuvanted immunogeniccomposition for the first administration may be given intramuscularly,and the boosting composition, either adjuvanted or not, may beadministered through a different route, for example intradermal,subcutaneous or intranasal. In a specific embodiment, the compositionfor the first administration contains a HA amount of less than 15 μg forthe pandemic influenza strain, and the boosting composition may containa standard amount of 15 μg or, suitably a low amount of HA, i.e., below15 μg, which, depending on the administration route, may be given in asmaller volume.

Populations to Vaccinate

The target population to vaccinate is the entire population, e.g.healthy young adults (e.g. aged 18-60), elderly (typically aged above60) or infants/children. The target population may in particular beimmuno-compromised. Immuno-compromised humans generally are less wellable to respond to an antigen, in particular to an influenza antigen, incomparison to healthy adults.

In one aspect according to the invention, the target population is apopulation which is unprimed against influenza, either being naïve (suchas vis à vis a pandemic strain), or having failed to respond previouslyto influenza infection or vaccination. Suitably the target population iselderly persons suitably aged at least 60, or 65 years and over, youngerhigh-risk adults (i.e., between 18 and 60 years of age) such as peopleworking in health institutions, or those young adults with a risk factorsuch as cardiovascular and pulmonary disease, or diabetes. Anothertarget population is all children 6 months of age and over, especiallychildren 6-23 months of age who experience a relatively highinfluenza-related hospitalization rate. Another target population isyounger children from birth to 6 months of age.

Vaccination Regimes, Dosing and Efficacy Criteria

Suitably the immunogenic compositions according to the present inventionare a standard 0.5 ml injectable dose in most cases, and contains lessthan 15 μg of haemagglutinin antigen component from a pandemic influenzastrain, as measured by single radial immunodiffusion (SRD) (J. M. Woodet al.: J. Biol. Stand. 5 (1977) 237-247; J. M. Wood et al., J. Biol.Stand. 9 (1981) 317-330). Suitably the vaccine dose volume will bebetween 0.5 ml and 1 ml, in particular a standard 0.5 ml, or 0.7 mlvaccine dose volume. Slight adaptation of the dose volume will be maderoutinely depending on the HA concentration in the original bulk sampleand depending also on the delivery route with smaller doses being givenby the intranasal or intradermal route.

Suitably said immunogenic composition contains a low amount of HAantigen—e.g any of 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 μg ofHA per influenza strain or which does not exceed 15 μg of HA per strain.Said low amount of HA amount may be as low as practically feasibleprovided that it allows to formulate a vaccine which meets theinternational e.g. EU or FDA criteria for efficacy, as detailed below(see Table 1 and the specific parameters as set forth). A suitable lowamount of HA is between 1 to 7.5 μg of HA per influenza strain, suitablybetween 3.5 to 5 μg such as 3.75 or 3.8 μg of HA per influenza strain,typically about 5 μg of HA per influenza strain. Another suitable amountof HA is between 0.1 and 5 μg of HA per influenza strain, suitablybetween 1.0 and 2 μg of HA per influenza strain such as 1.9 μg of HA perinfluenza strain.

Advantageously, a vaccine dose according to the invention, in particulara low HA amount vaccine, may be provided in a smaller volume than theconventional injected split flu vaccines, which are generally around0.5, 0.7 or 1 ml per dose. The low volume doses according to theinvention are suitably below 500 μl, typically below 300 μl and suitablynot more than about 200 μl or less per dose.

Thus, a suitable low volume vaccine dose according to one aspect of theinvention is a dose with a low antigen dose in a low volume, e.g. about15 μg or about 7.5 μg HA or about 3.0 μg HA (per strain) in a volume ofabout 200 μl.

The influenza medicament of the invention suitably meets certaininternational criteria for vaccines. Standards are appliedinternationally to measure the efficacy of influenza vaccines.

Serological variables are assessed according to criteria of the EuropeanAgency for the Evaluation of Medicinal Products for human use(CHMP/BWP/214/96, Committee for Proprietary Medicinal Products (CPMP).Note for harmonization of requirements for influenza vaccines, 1997.CHMP/BWP/214/96 circular N^(o) 96-0666:1-22) for clinical trials relatedto annual licensing procedures of influenza vaccines (Table 1). Therequirements are different for adult populations (18-60 years) andelderly populations (>60 years) (Table 1). For interpandemic influenzavaccines, at least one of the assessments (seroconversion factor,seroconversion rate, seroprotection rate) should meet the Europeanrequirements, for all strains of influenza included in the vaccine. Theproportion of titres equal or greater than 1:40 is regarded mostrelevant because these titres are expected to be the best correlate ofprotection [Beyer W et al. 1998. Clin Drug Invest.; 15:1-12].

As specified in the “Guideline on dossier structure and content forpandemic influenza vaccine marketing authorisation application”(CHMP/VEG/4717/03, Apr. 5, 2004, or more recentlyEMEA/CHMP/VWP/263499/2006 of 24 Jan. 2007 entitled ‘Guidelines on fluvaccines prepared from viruses with a potential to cause a pandemic’,available on www.emea.eu.int), in the absence of specific criteria forinfluenza vaccines derived from non circulating strains, it isanticipated that a pandemic candidate vaccine should (at least) be ableto elicit sufficient immunological responses to meet suitably all threeof the current standards set for existing vaccines in unprimed adults orelderly subjects, after two doses of vaccine. The EMEA Guidelinedescribes the situation that in case of a pandemic the population willbe immunologically naive and therefore it is assumed that all three CHMPcriteria for seasonal vaccines will be fulfilled by pandemic candidatevaccines. No explicit requirement to prove it in pre-vaccinationseronegative subjects is required.

The compositions of the present invention suitably meet at least onesuch criteria for the pandemic strain included in the composition (onecriteria is enough to obtain approval), suitably at least two, ortypically at least all three criteria for protection as set forth inTable 1A.

TABLE 1A (CHMP criteria) 18-60 years >60 years Seroconversionrate* >40% >30% Conversion factor** >2.5  >2.0  Protectionrate*** >70% >60% *Seroconversion rate is defined as the proportion ofsubjects in each group having a protective post-vaccination titre ≥1:40.The seroconversion rate simply put is the % of subjects who have an HItitre before vaccination of <1:10 and ≥1:40 after vaccination. However,if the initial titre is ≥1:10 then there needs to be at least a fourfoldincrease in the amount of antibody after vaccination. **Conversionfactor is defined as the fold increase in serum HI geometric mean titres(GMTs) after vaccination, for each vaccine strain. ***Protection rate isdefined as the proportion of subjects who were either seronegative priorto vaccination and have a (protective) post-vaccination HI titre of≥1:40 or who were seropositive prior to vaccination and have asignificant 4-fold increase in titre post-vaccination; it is normallyaccepted as indicating protection.

A 70% seroprotection rate is defined by the European health regulatoryauthority (CHMP—Committee for Medicinal Products for Human Use) is oneof three criteria normally required to be met for an annual seasonalinfluenza vaccine and which CHMP is also expecting a pandemic candidatevaccine to meet. However, mathematical modelling has indicated that avaccine that is, at the population level, only 30% efficient againstcertain drifted strains may also be of benefit in helping to reduce themagnitude of a pandemic and that a pandemic vaccination campaign using a(pre-pandemic) vaccine with 30% efficacy against the pandemic strain(cross-protection of 30%) could effectively reduce the clinical attackrate by 75% and consequently morbidity/mortality within the population(Ferguson et al, Nature 2006).

FDA has published a draft guidance (CBER draft criteria) (available fromthe Office of Communication, Training and Manufacturers Assistance(HFM-40), 1401 Rockville Pike, Suite 200N, Rockville, Md. 20852-1448, orby calling 1-800-835-4709 or 301-827-1800, or from the Internet athttp://www.fda.gov/cber/guidelines.htm) on Clinical Data Needed toSupport the Licensure of Pandemic Influenza Vaccines, and the proposedcriteria are also based on the CHMP criteria. FDA uses slightlydifferent age cut-off points. Appropriate endpoints similarlyinclude: 1) the percent of subjects achieving an HI antibody titer≥1:40, and 2) rates of seroconversion, defined as a four-fold rise in HIantibody titer post-vaccination. The geometric mean titer (GMT) shouldbe included in the results, but the data should include not only thepoint estimate, but also the lower bound of the 95% confidence intervalof the incidence rate of seroconversion, and the day 42 incidence rateof HI titers ≥1:40 must exceed the target value. These data and the 95%confidence intervals (CI) of the point estimates of these evaluationsshould therefore be provided. FDA draft guidance requires that bothtargets be met. This is summarised in Table 1B.

TABLE 1B (CBER draft criteria) 18-64 years >64 years Seroconversionrate* >40% >30% Rate of HI titers ≥1:40 >70% >60% *The seroconversionrate is is defined as: a) for subjects with a baseline titer ≥1:10, a4-fold or greater rise; or b) for subjects with a baseline titer <1:10,a rise to ≥1:40. These criteria must be met at the lower bound of the95% CI for the true value.

Accordingly, in one aspect of the invention, it is provided for acomposition, method or use as claimed herein wherein said immuneresponse or protection induced by the administration of the contemplatedpandemic composition meets all three EU regulatory criteria forinfluenza vaccine efficacy. Suitably at least one, suitably two, orthree of following criteria are met for the pandemic strain of thecomposition:

-   -   a seroconversion rate of >50%, of >60%, of >70%, suitably        of >80% or >90% in the adult population (aged 18-60), and/or        suitably also in the elderly population (aged >60 years);    -   a protection rate of >75%, of >80%, of >85%, suitably of >90% in        the adult population (aged 18-60), and/or suitably also in the        elderly population (aged >60 years);    -   a conversion factor of >4.0, of >5.0, of >6.0, of >7.0, of >8.0,        of >9.0 or of 10 or above 10 in the adult population (aged        18-60), and/or suitably also in the elderly population (aged >60        years).

In a specific embodiment the composition according to the invention willmeet both a seroconversion rate of >60%, or >70%, or suitably >80% and aprotection rate of >75%, suitably of >80% in the adult population. Inanother specific embodiment the composition according to the inventionwill meet both a conversion factor of >5.0, or >7.0 or suitably >10.0and a seroconversion rate of >60%, or >70%, or suitably >80% in theadult population. In another specific embodiment, the compositionaccording to the invention will meet both a conversion factor of >5.0,or >7.0 or suitably >10.0, and a protection rate of >75%, suitably >80%in the adult population. In still another specific embodiment thecomposition according to the invention will meet both a conversionfactor of 10.0 or above, a seroconversion rate of 80% or above, and aprotection rate of 80% or above.

In another embodiment, the claimed vaccine, suitably a pre-pandemicvaccine, will have 30% efficacy against the circulating pandemic strain(cross-protection of 30%). In particular the claimed vaccine will meet aseroprotection rate of at least 30% against drifted strains, suitably ofat least 40%, or >50% or >60% against drifted strains. Suitably theseroprotection rate will be >70%, or suitably >80% against driftstrains. Said pre-pandemic vaccine, capable of conferringcross-protection, will be able to reduce substantially the overallinfection attack rate, by at least 50%, or suitably at least 75%, andconsequently morbidity/mortality within the population.

In still another embodiment, the claimed adjuvanted vaccine is able toinduce neutralizing antibodies in at least 50% of subjects, at least60%, suitable at least 70%, or suitably in more than 75% of subjectsagainst a drifted strain or a strain from a different clade. Suitablythis effect is achieved with a low dose of antigen, such as with 7.5 μgHA or even a lower antigen dose such as 3.8 μg or 1.9 μg of HA.

Suitably any or all of such criteria are also met for other populations,such as in children and in any immuno-compromised population.

Suitably the above response(s) is(are) obtained after one dose, ortypically after two doses. It is a particular advantage of the claimedcomposition that the immune response is obtained after only one dose ofadjuvanted vaccine. Accordingly, there is provided in one aspect of theinvention the use of a non-live pandemic influenza virus antigenpreparation, in particular a split influenza virus preparation, in themanufacture of a vaccine composition for a one-dose vaccination againstinfluenza, wherein the one-dose vaccination generates an immune responsewhich meets at least one, suitably two or three, internationalregulatory requirements for influenza vaccines. In another particularembodiment said one-dose vaccination also or additionally generates aCD4 T cell immune response and/or a B cell memory response which ishigher than that obtained with the non adjuvanted vaccine. In aparticular embodiment said immune response is a cross-reactive antibodyresponse or a cross-reactive CD4 T cell response or both. In a specificembodiment the human patient is immunologically naïve (i.e., does nothave pre-existing immunity) to the vaccinating strain. Specifically thevaccine composition contains a low HA antigen amount. Specifically thevaccine composition is as defined herein. In particular the immunogenicproperties of the vaccine composition are as defined herein. Suitablythe vaccine is administered intramuscularly.

In respect of the composition for revaccination, when it is amultivalent composition, at least two or all three of the criteria willneed to be met for all strains, particularly for a new vaccine such as anew vaccine for delivery via a different route. Under some circumstancestwo criteria may be sufficient. For example, it may be acceptable fortwo of the three criteria to be met by all strains while the thirdcriterion is met by some but not all strains (e.g. two out of threestrains).

In a further aspect the invention provides a method of designing avaccine for diseases known to be cured or treated through a CD4+ T cellactivation, comprising

-   -   1) selecting an antigen containing CD4+ epitopes, and    -   2) combining said antigen with an oil-in-water emulsion adjuvant        as defined herein above, wherein said vaccine upon        administration in said mammal is capable of inducing an enhanced        CD4 T cell response in said mammal.

The teaching of all references in the present application, includingpatent applications and granted patents, are herein fully incorporatedby reference. Any patent application to which this application claimspriority is incorporated by reference herein in its entirety in themanner described herein for publications and references.

For the avoidance of doubt the terms ‘comprising’, ‘comprise’ and‘comprises’ herein is intended by the inventors to be optionallysubstitutable with the terms ‘consisting of’, ‘consist of’, and‘consists of’, respectively, in every instance.

The invention will be further described by reference to the following,non-limiting, examples:

Example I describes immunological read-out methods used in mice, ferretsand human studies.

Example II describes the preparation and characterization of the oil inwater emulsion and adjuvant formulations used in the studiesexemplified.

Example III shows a pre-clinical evaluation of adjuvanted andun-adjuvanted influenza vaccines in ferrets.

Example IV describes a clinical trial in an adult population aged 18-60years with a vaccine containing a split influenza antigen preparationfrom a pandemic H5N1 strain and AS03 adjuvant.

Example V shows a pre-clinical evaluation of adjuvanted and unadjuvantedsplit influenza vaccines (comprising H5N1 strain) in C57Bl/6 naive mice.

Example VI shows a pre-clinical evaluation of an adjuvanted pandemicsplit influenza vaccines (comprising H5N1 strain) after heterologouschallenge in ferrets.

Example I—Immunological Read-Out Methods I.1. Ferrets Methods

Suitable methods are given below which are routinely used forexperiments performed with seasonal strains. The skilled reader willunderstand that it may need some adaptation or optimization depending onthe influenza strain used.

I.1.1. Hemagglutination Inhibition Test (HI) Test Procedure.

Anti-Hemagglutinin antibody titers to the influenza virus strain aredetermined using the hemagglutination inhibition test (HI). Theprinciple of the HI test is based on the ability of specificanti-Influenza antibodies to inhibit hemagglutination of horse red bloodcells (RBC) by influenza virus hemagglutinin (HA). After pre-treatmentof sera (cholera, RDE, heat inactivation, . . . ), two-fold dilutions ofsera are incubated with 4 hemagglutination units of the influenzastrain. Horse (adaptation: turkey, or horse) red blood cells are thenadded and the inhibition of agglutination is scored. The titers areexpressed as the reciprocal of the highest dilution of serum thatcompletely inhibited hemagglutination. As the first dilution of sera was1:10, an undetectable level was scored as a titer equal to 5. Moredetails can be found in the section 1.2.1. below.

I.1.2. Body Temperature Monitoring

Body temperature was registered by means of temperature sensors (StarOddi, Iceland) implanted on Day −14 under anesthesia withketamine-rompun-atropine mix (2.5%-0.25%-0.025%) via small incision inthe linea alba into the peritoneal cavity. The wound was closed withstitches and inspected daily.

I.2.3. Viral Titration

Pharyngeal, nasal and rectal swabs were collected from all animals.Individual swabs were placed in 3 ml virus transport medium (VTM;sterile PBS or suitable isotonic solution such as Hank's BSS containingantibiotics (100 units/ml penicillin, 100 μg/ml streptomycin) and either2% fetal bovine serum or 0.5% gelatin) and stored at −80° C. untilanalysis. After necropsy cranioventral, craniodorsal, caudoventral andcaudodorsal sections of the right lung from each animal were weighed andstored at −80° C. until analysis. Lung sections were homogenized in 3 mlVTM. Viral titers were determined by means of H5N1-specific TagMan™ PCRand virus titration culture on Madine Darby canine kidney (MDCK) cells.

For the TaqMan™ PCR, viral H5N1 Flu RNAs were extracted from ferretsamples and then amplified by a quantitative RT-PCR assay using primersand probes designed in a conserved region of the Influenza genome. Datawere expressed as Control Dilution Units (CDU) and TCID₅₀ per gram oflung tissue or per ml of swab, respectively. Control Dilution Units(CDU)—CDUs are determined from a standard curve produced from a stock ofvirus which is serially diluted, with each dilution undergoing nucleicacid extraction and Taqman™ PCR amplification in the same manner as testsamples.

For the viral culture, serial dilutions of all samples were transferredto microtiter plates containing medium and MDCK cells and then incubatedat 35° C. for 5-7 days. After incubation, the viral shedding titers weredetermined by “Reed and Muench” and expressed as Log TCID50 per gram oflung tissue or per ml of swab.

I.1.4. Neutralizing Antibody Assay

Neutralizing antibody measurements were conducted on thawed frozen serumsamples. Virus neutralization by antibodies contained in the serum isdetermined in a microneutralization assay. The sera are used withoutfurther treatment in the assay. Each serum is tested in triplicate. Astandardised amount of virus is mixed with serial dilutions of serum andincubated to allow binding of the antibodies to the virus. A cellsuspension, containing a defined amount of MDCK cells is then added tothe mixture of virus and antiserum and incubated at 33° C. After theincubation period, virus replication is visualised by hemagglutinationof chicken red blood cells. The 50% neutralization titre of a serum iscalculated by the method of Reed and Muench (Am. J. Hyg. 1938, 27:493-497).

I.2. Assays for assessing the immune response in humans

I.2.1. Hemagglutination Inhibition Assay

The immune response was determined by measuring HI antibodies using themethod described by the WHO Collaborating Centre for influenza, Centresfor Disease Control, Atlanta, USA (1991).

Antibody titre measurements were conducted on thawed frozen serumsamples with a standardised and comprehensively validated micromethodusing 4 hemagglutination-inhibiting units (4 HIU) of the appropriateantigens and a 0.5% fowl (or 0.5% fowl and horse for H5N1) erythrocytesuspension. Non-specific serum inhibitors were removed by heat treatmentand receptor-destroying enzyme.

The sera obtained were evaluated for HI antibody levels. Starting withan initial dilution of 1:10, a dilution series (by a factor of 2) wasprepared up to an end dilution of 1:20480. The titration end-point wastaken as the highest dilution step that showed complete inhibition(100%) of hemagglutination. All assays were performed in duplicate.

Adaptation for H5N1 Specific Description of HI Using Horse Erythrocytes:

Glycoproteins (haemaglutinins) are located in the viral envelope, andare able to agglutinate erythrocytes (red blood cells) of many speciese.g. chicken.

The haemagglutination inhibition test is carried out in two steps:

-   1. Antigen-antibody reaction: the Influenza antigen (DTA, dialysis    test antigen) reacts with the antibodies of the subject's serum.-   2. Agglutination of excessive antigen: excessive antigen reacts with    added red blood cells Erythrocytes of horses are used for the H5N1    Pandemic strains.

0.5% (end concentration) horse red blood cell suspension in phosphatebuffer containing 0.5% BSA (bovine serum albumin, end concentration).

This suspension is prepared every day by washing red blood cell with thesame phosphate buffer and a subsequent centrifugation step (10 min, 2000rpm). This washing step has to be repeated once.

After the addition of the horse red blood cells to the reaction mix ofpatient/subject sera and virus suspension the plates have to beincubated at room temperature (RT, 20° C.+/−2° C.) for two hours due tothe low sedimentation rate of the horse red blood cells.

I.2.2. Neuraminidase Inhibition Assay

The assay was performed in fetuin-coated microtitre plates. A 2-folddilution series of the antiserum was prepared and mixed with astandardised amount of influenza A H3N2, H1N1 or influenza B virus. Thetest was based on the biological activity of the neuraminidase whichenzymatically releases neuraminic acid from fetuin. After cleavage ofthe terminal neuraminic acid β-D-glactose-N-acetyl-galactosamin wasunmasked. Horseradish peroxidase (HRP)-labelled peanut agglutinin fromArachis hypogaea, which binds specifically to the galactose structures,was added to the wells. The amount of bound agglutinin can be detectedand quantified in a substrate reaction with tetra-methylbenzidine (TMB)The highest antibody dilution that still inhibits the viralneuraminidase activity by at least 50% was indicated is the NI titre.

I.2.3. Neutralising Antibody Assay

Neutralising antibody measurements were conducted on thawed frozen serumsamples. Virus neutralisation by antibodies contained in the serum isdetermined in a microneutralization assay. The sera are used withoutfurther treatment in the assay. Each serum is tested in triplicate. Astandardised amount of virus is mixed with serial dilutions of serum andincubated to allow binding of the antibodies to the virus. A cellsuspension, containing a defined amount of MDCK cells is then added tothe mixture of virus and antiserum and incubated at 33° C. After theincubation period, virus replication is visualised by hemagglutinationof chicken red blood cells. The 50% neutralisation titre of a serum iscalculated by the method of Reed and Muench (Am. J. Hyg. 1938, 27:493-497).

I.2.4. Cell-Mediated Immunity was Evaluated by Cytokine Flow Cytometry(CFC)

Peripheral blood antigen-specific CD4 and CD8 T cells can berestimulated in vitro to produce IL-2, CD40L, TNF-alpha and IFN ifincubated with their corresponding antigen. Consequently,antigen-specific CD4 and CD8 T cells can be enumerated by flow cytometryfollowing conventional immunofluorescence labelling of cellularphenotype as well as intracellular cytokines production. In the presentstudy, Influenza vaccine antigen are used as antigen to restimulateInfluenza-specific T cells. Results are expressed as a frequency ofcytokine(s)-positive CD4 or CD8 T cell within the CD4 or CD8 T cellsub-population.

I.2.5. Memory B Cells by ELISPOT

The ELISPOT technology allows the quantification of memory B cellsspecific to a given antigen. Memory B-cells can be induced todifferentiate into plasma cells in vitro following cultivation with CpGfor 5 days. In vitro generated antigen-specific plasma cells cantherefore be enumerated using the ELISPOT assay. Briefly, in vitrogenerated plasma cells are incubated in culture plates coated withantigen. Antigen-specific plasma cells form antibody/antigen spots,which can be detected by conventional immuno-enzymatic procedure. In thepresent study, influenza vaccine strains or anti-human Immunoglobulinsare used to coat culture plates in order to enumerate influenza-specificantibody or IgG secreting plasma cells, respectively. Results areexpressed as a frequency of influenza-specific antibody secreting plasmacells within the IgG-producing plasma cells.

I.2.6. Statistical Methods I.2.6.1. Primary Endpoints

-   -   Percentage, intensity and relationship to vaccination of        solicited local and general signs and symptoms during a 7 day        follow-up period (i.e., day of vaccination and 6 subsequent        days) after vaccination and overall.    -   Percentage, intensity and relationship to vaccination of        unsolicited local and general signs and symptoms during a 21 day        follow-up period (i.e., day of vaccination and 20 subsequent        days) after vaccination and overall.    -   Occurrence of serious adverse events during the entire study.

I.2.6.2. Secondary Endpoints For the Humoral Immune Response: ObservedVariables:

-   -   At days 0 and 21: serum hemagglutination-inhibition (HI) and NI        antibody titres, tested separately against each of the three        influenza virus strains represented in the vaccine (anti-H1N1,        anti-H3N2 & anti-B-antibodies).    -   At days 0 and 21: neutralising antibody titres, tested        separately against each of the three influenza virus strains        represented in the vaccine        Derived Variables (with 95% Confidence Intervals):    -   Geometric mean titres (GMTs) of serum HI antibodies with 95%        confidence intervals (95% CI) pre and post-vaccination    -   Seroconversion rates* with 95% CI at day 21    -   Conversion factors** with 95% CI at day 21    -   Seroprotection rates*** with 95% CI at day 21    -   Serum NI antibody GMTs' (with 95% confidence intervals) at all        timepoints.        *Seroconversion rate defined as the percentage of vaccinees who        have at least a 4-fold increase in serum HI titres on day 21        compared to day 0, for each vaccine strain.        **Conversion factor defined as the fold increase in serum HI        GMTs on day 21 compared to day 0, for each vaccine strain.        ***Protection rate defined as the percentage of vaccinees with a        serum HI titre=40 after vaccination (for each vaccine strain)        that usually is accepted as indicating protection.

For the Cell Mediated Immune (CMI) Response Observed Variable

At days 0 and 21: frequency of cytokine-positive CD4/CD8 cells per 10⁶in different tests. Each test quantifies the response of CD4/CD8 T cellto:

-   -   Peptide Influenza (pf) antigen (the precise nature and origin of        these antigens needs to be given/explained    -   Split Influenza (sf) antigen    -   Whole Influenza (wf) antigen.

Derived Variables:

-   -   cells producing at least two different cytokines (CD40L, IL-2,        IFNγ, TNFα)    -   cells producing at least CD40L and another cytokine (IL-2, TNFα,        IFNγ)    -   cells producing at least IL-2 and another cytokine (CD40L, TNFα,        IFNγ)    -   cells producing at least IFNγ and another cytokine (IL-2, TNFα,        CD40L)    -   cells producing at least TNFα and another cytokine (IL-2, CD40L,        IFNγ)

I.3.5.3. Analysis of Immunogenicity

The immunogenicity analysis was based on the total vaccinated cohort.For each treatment group, the following parameters (with 95% confidenceintervals) were calculated:

-   -   Geometric mean titres (GMTs) of HI and NI antibody titres at        days 0 and 21    -   Geometric mean titres (GMTs) of neutralising antibody titres at        days 0 and 21.    -   Conversion factors at day 21.    -   Seroconversion rates (SC) at day 21 defined as the percentage of        vaccinees that have at least a 4-fold increase in serum HI        titres on day 21 compared to day 0.    -   Protection rates at day 21 defined as the percentage of        vaccinees with a serum HI titre=1:40.    -   The frequency of CD4/CD8 T-lymphocytes secreting in response was        summarised (descriptive statistics) for each vaccination group,        at each timepoint (Day 0, Day 21) and for each antigen (Peptide        influenza (pf), split influenza (sf) and whole influenza (wf)).    -   Descriptive statistics in individual difference between        timepoint (Post-Pre) responses fore each vaccination group and        each antigen (pf, sf, and wf) at each 5 different tests.    -   A non-parametric test (Kruskall-Wallis test) was used to compare        the location differences between the 3 groups and the        statistical p-value was calculated for each antigen at each 5        different tests. All significance tests were two-tailed.        P-values less than or equal to 0.05 were considered as        statistically significant.

I.3. Mice Methods I.3.1. Anti-H5N1 ELISA.

Quantitation of anti-H5N1 IgG antibody was performed by ELISA usingSplit H5N1 as coating. Virus and antibody solutions were used at 100 μlper well. Split virus H5N1 was diluted at a final concentration of 1μg/ml in PBS and was adsorbed overnight at 4° C. to the wells of 96wells microtiter plates (Maxisorb Immunoplate Nunc 439454). The plateswere then incubated for 1 hour at 37° C. with 200 μl per well of PBScontaining 1% BSA and 0.1% TWEEN™ 20 (saturation buffer). Twelvetwo-fold dilutions of sera in saturation buffer were added to theH5N1-coated plates and incubated for 1 h 30 at 37° C. The plates werewashed four times with PBS 0.1% TWEEN™ 20. Peroxidase-conjugatedanti-mouse IgG (Sigma A5278) diluted 1/1000 in PBS 1% BSA 0.1% TWEEN™ 20was added to each well and incubated for 1 hour at 37° C. After awashing step, plates were incubated 20 min at 22° C. with a solution ofo-phenyldiamine (Sigma P4664) 0.04% H₂O₂ 0.03% in 0.1 M citrate bufferpH 4.2. The reaction was stopped with H₂SO₄ 2N and microplates were readat 490-630 nm.

I.3.2. Hemagglutination Inhibition (HI) Assay.

The protocol used was adapted from the classical HI assay fordetermining anti-HA antibodies, and relied on the use of horse RBC.

Test Principle (Classical Procedure)

Anti-Hemagglutinin antibody titers to the three (seasonal) influenzavirus strains are determined using the hemagglutination inhibition test(HI). The principle of the HI test is based on the ability of specificanti-Influenza antibodies to inhibit hemagglutination of red blood cells(RBC) by influenza virus hemagglutinin (HA). Heat inactivated sera aretreated by Kaolin and RBC to remove non-specific inhibitors. Afterpretreatment, two-fold dilutions of sera are incubated with 4hemagglutination units of each influenza strain. Red blood cells arethen added and the inhibition of agglutination is scored. The titers areexpressed as the reciprocal of the highest dilution of serum thatcompletely inhibited hemagglutination. As the first dilution of sera is1:20, an undetectable level is scored as a titer equal to 10.

Adaptation for H5N1 (Specific Description of HI Using HorseErythrocytes)

Erythrocytes of horses are used for the H5N1 Pandemic strains. 0.5% (endconcentration) horse red blood cell suspension in phosphate buffercontaining 0.5% BSA (bovine serum albumin, end concentration). Thissuspension is prepared every day by washing red blood cell with the samephosphate buffer and a subsequent centrifugation step (10 min, 2000rpm). This washing step has to be repeated once. After the addition ofthe horse red blood cells to the reaction mix of sera and virussuspension; the plates have to be incubated at room temperature (RT, 20°C.+/−2° C.) for two hours due to the low sedimentation rate of the horsered blood cells.

Statistical Analysis

Statistical analysis were performed on post vaccination HI titers usingUNISTAT. The protocol applied for analysis of variance can be brieflydescribed as follow:

-   -   Log transformation of data    -   Shapiro-Wilk test on each population (group) in order to verify        the normality of groups distribution    -   Cochran test in order to verify the homogenicity of variance        between the different populations (groups)    -   Analysis of variance on selected data.    -   Test for interaction of two-way ANOVA    -   Tukey-HSD Test for multiple comparisons

I.3.3. Intracellular Cytokine Staining (ICS).

This technique allows a quantification of antigen specific T lymphocyteson the basis of cytokine production: effector T cells and/oreffector-memory T cells produce IFN-γ and/or central memory T cellsproduce IL-2.

Intracellular staining of cytokines of T cells was performed on PBMC 7days after the immunization. Blood was collected from mice and pooled inheparinated medium RPMI+Add*. For blood, RPMI+Add-diluted PBLsuspensions were layered onto a Lympholyte-Mammal gradient according tothe recommended protocol (centrifuge 20 minutes at 2500 rpm and R.T.).The mononuclear cells at the interface were removed, washed 2-fold inRPMI+Add and PBMCs suspensions were adjusted to 10⁷ cells/ml in RPMI 5%fetal calf serum.

* Composition of RM PI+Add

RPMI 1640 without L-glutamine (Gibco 31870-025/041-01870M)+Additives (for 500 ml RPMI): 5 ml sodium pyruvate 100 mM (Gibco lot11360-039), 5 ml MEM non essential amino acids ((Gibco lot 11140-035), 5ml Pen/Strep (Gibco lot 20F9252), 5 ml glutamine (Gibco lot 24Q0803),500 μl 2-mercaptoethanol 1000× (Gibco ref. 31350-010).

In vitro antigen stimulation of PBMCs was carried out at a finalconcentration of 10⁶ cells/wells (microplate) with Formalin-inactivatedsplit 1 μg HA/strain and then incubated 2 hours at 37° C. with theaddition of anti-CD28 and anti-CD49d (1 μg/ml for the both). Theaddition of both antibodies increased proliferation and cytokineproduction by activated T and NK cells and can provide a costimulatorysignal for CTL induction.

Following the antigen restimulation step, PBMC are incubated O.N. at 37°C. in presence of Brefeldin (1 μg/ml) at 37° C. to inhibit cytokinesecretion. IFN-γ/IL-2/CD4/CD8 staining was performed as follows: cellsuspensions were washed, resuspended in 50 μl of PBS 1% FCS containing2% Fc blocking reagent (1/50; 2.4G2). After 10 minutes incubation at 4°C., 50 μl of a mixture of anti-CD4-PE (2/50) and anti-CD8 perCp (3/50)was added and incubated 30 minutes at 4° C. After a washing in PBS 1%FCS, cells were permeabilized by resuspending in 200 μl ofCytofix-Cytoperm (Kit BD) and incubated 20 minutes at 4° C. Cells werethen washed with Perm Wash (Kit BD) and resuspended with 50 μl of a mixof anti-IFN-γ APC (1/50)+anti-IL-2 FITC (1/50) diluted in Perm Wash.After incubation (minimum 2 hours and maximum overnight) at 4° C., cellswere washed with Perm Wash and resuspended in PBS 1% FCS+1%paraformaldehyde. Sample analysis was performed by FACS. Live cells weregated (FSC/SSC) and acquisition was performed on ˜50,000 events(lymphocytes) or 15,000 events on CD4+ T cells. The percentages ofIFN-γ+ or IL2+ were calculated on CD4+ and CD8+ gated populations.

Example II—Preparation and Characterization of the Oil in Water Emulsionand Adjuvant Formulations

Unless otherwise stated, the oil/water emulsion used in the subsequentexamples is composed an organic phase made of 2 oils (alpha-tocopheroland squalene), and an aqueous phase of PBS containing TWEEN™ 80 asemulsifying agent. Unless otherwise stated, the oil in water emulsionadjuvant formulations used in the subsequent examples were madecomprising the following oil in water emulsion component (finalconcentrations given): 2.5% squalene (v/v), 2.5% alpha-tocopherol (v/v),0.9% polyoxyethylene sorbitan monooleate (v/v) (TWEEN™ 80), see WO95/17210. This emulsion, termed AS03 in the subsequent examples, wasprepared as followed as a two-fold concentrate.

II.1. Preparation of Emulsion SB62 II.1.1. Lab-Scale Preparation

TWEEN™ 80 is dissolved in phosphate buffered saline (PBS) to give a 2%solution in the PBS. To provide 100 ml two-fold concentrate emulsion 5 gof DL alpha tocopherol and 5 ml of squalene are vortexed to mixthoroughly. 90 ml of PBS/TWEEN™ solution is added and mixed thoroughly.The resulting emulsion is then passed through a syringe and finallymicrofluidised by using an M110S microfluidics machine. The resultingoil droplets have a size of approximately 120-180 nm (expressed as Zaverage measured by PCS).

The other adjuvants/antigen components are added to the emulsion insimple admixture.

II.1.2. Scaled-Up Preparation

This method was used in the studies reported in the clinical andpre-clinical examples sections. The preparation of the SB62 emulsion ismade by mixing under strong agitation of an oil phase composed ofhydrophobic components (α-tocopherol and squalene) and an aqueous phasecontaining the water soluble components (TWEEN™ 80 and PBS mod(modified), pH 6.8). While stirring, the oil phase (1/10 total volume)is transferred to the aqueous phase (9/10 total volume), and the mixtureis stirred for 15 minutes at room temperature. The resulting mixturethen subjected to shear, impact and cavitation forces in the interactionchamber of a microfluidizer (15000 PSI—8 cycles) to produce submicrondroplets (distribution between 100 and 200 nm). The resulting pH isbetween 6.8±0.1. The SB62 emulsion is then sterilised by filtrationthrough a 0.22 μm membrane and the sterile bulk emulsion is storedrefrigerated in Cupac containers at 2 to 8° C. Sterile inert gas(nitrogen or argon) is flushed into the dead volume of the SB62 emulsionfinal bulk container for at least 15 seconds.

The final composition of the SB62 emulsion is as follows:

TWEEN™ 80: 1.8% (v/v) 19.4 mg/ml; Squalene: 5% (v/v) 42.8 mg/ml;α-tocopherol: 5% (v/v) 47.5 mg/ml; PBS-mod: NaCl 121 mM, KCl 2.38 mM,Na2HPO4 7.14 mM, KH2PO4 1.3 mM; pH 6.8±0.1.

II.2. Measure of Oil Droplet Size Dynamic Light Scattering II.2.1.Introduction

The size of the diameter of the oil droplets is determined according tothe following procedure and under the following experimental conditions.The droplet size measure is given as an intensity measure and expressedas z average measured by PCS.

II.2.2. Sample Preparation

Size measurements have been performed on the oil-in-water emulsionadjuvant: SB62 prepared following the scaled-up method, AS03 andAS03+MPL (50 μg/ml), the last two being prepared just before use. Thecomposition of the samples is given below (see section II.2.4). Sampleswere diluted 4000×-8000× in PBS 7.4.

As a control, PL-Nanocal Particle size standards 100 nm (cat n°6011-1015) was diluted in 10 mM NaCl.

II.2.3. Malvern Zetasizer 3000HS Size Measurements

All size measurements were performed with both Malvern Zetasizer 3000HS.

Samples were measured into a plastic cuvette for Malvern analysis at asuitable dilution (usually at a dilution of 4000× to 20000× depending onthe sample concentration), and with two optical models:

-   -   either real particle refractive index of 0 and imaginary one of        0.    -   or real particle refractive index of 1.5 and imaginary one of        0.01 (the adapted optical model for the emulsion, according to        the values found in literature).

The technical conditions were:

-   -   laser wavelength: 532 nm (Zeta3000HS).    -   laser power: 50 mW (Zeta3000HS).    -   scattered light detected at 90° (Zeta3000HS).    -   temperature: 25° C.,    -   duration: automatic determination by the soft,    -   number: 3 consecutive measurements,    -   z-average diameter: by cumulants analysis    -   size distribution: by the Contin or the Automatic method.

The Automatic Malvern algorithm uses a combination of cumulants, Continand non negative least squares (NNLS) algorithms.

The intensity distribution may be converted into volume distributionthanks to the Mie theory.

II.2.4. Results (see Table 2) Cumulants Analysis (Z Average Diameter):

TABLE 2 Count Poly- Sample Dilution Record rate ZAD dispersity SB62 50001 7987 153 0.06 2 7520 153 0.06 3 6586 152 0.07 average 7364 153 0.06SB62 (Example IV) 8000 1 8640 151 0.03 2 8656 151 0.00 3 8634 150 0.00average 8643 151 0.01 SB62 + MPL 25 μg (*) 8000 1 8720 154 0.03 2 8659151 0.03 3 8710 152 0.02 average 8697 152 0.02 (*) Prepared as follows:Water for injection, PBS 10× concentrated, 250 μl of SB62 emulsion and25 μg of MPL are mixed together to reach a final volume of 280 μl.

The z-average diameter (ZAD) size is weighed by the amount of lightscattered by each size of particles in the sample. This value is relatedto a monomodal analysis of the sample and is mainly used forreproducibility purposes.

The count rate (CR) is a measure of scattered light: it corresponds tothousands of photons per second.

The polydispersity (Poly) index is the width of the distribution. Thisis a dimensionless measure of the distribution broadness.

Contin and Automatic Analysis:

Two other SB62 preparations (2 fold concentrated AS03) have been madeand assessed according to the procedure explained above with thefollowing minor modifications:

Samples were measured into a plastic cuvette for Malvern analysis, attwo dilutions determined to obtain an optimal count rate values: 10000×and 20000× for the Zetasizer 3000HS, the same optical models as used inthe above example.

Results are shown in Table 3.

TABLE 3 Analysis in Analysis in Contin Automatic IR (mean in nm) (meanin nm) SB62 Dilution Real Imaginary Intensity Volume Intensity Volume1022 1/10000 0 0 149 167 150 — 1.5 0.01 158 139 155 143 1/20000 0 0 159200 155 196 1.5 0.01 161 141 147 — 1023 1/10000 0 0 158 198 155 — IG 1.50.01 161 140 150 144 1/20000 0 0 154 185 151 182 1.5 0.01 160 133 154 —“—” when the obtained values were not coherent.

FIG. 1A shows SB62 lot 1023 size measurements. A schematicrepresentation of these results is shown in FIG. 1B for formulation1023. As can be seen, the great majority of the particles (e.g. at least80%) have a diameter of less than 300 nm by intensity.

II.2.5. Overall Conclusion

SB62 formulation was measured at different dilutions with the MalvernZetasizer 3000HS and two optical models. The particle size ZAD (i.e.,intensity mean by cumulant analysis) of the formulations assessed abovewas around 150-155 nm.

When using the cumulants algorithm, we observed no influence of thedilution on the ZAD and polydispersity.

Example III—Pre-Clinical Evaluation of an Adjuvanted Pandemic SplitInfluenza Vaccines (Comprising H5N1 Strain) in Ferrets III.1. Rationaleand Objectives

Influenza infection in the ferret model closely mimics human influenza,with regards both to the sensitivity to infection and the clinicalresponse. The ferret is extremely sensitive to infection with bothinfluenza A and B viruses without prior adaptation of viral strains.Therefore, it provides an excellent model system for studies ofprotection conferred by administered influenza vaccines.

This study investigated the efficacy of H5N1 Split vaccines adjuvantedwith AS03 to protect ferrets against a lethal challenge with the H5N1homologous strain A/Vietnam/1194/2004 or with a heterologous strainA/Indonesia. The objective of this experiment was to demonstrate theefficacy of an adjuvanted influenza vaccine compared to ferretsimmunized with PBS or the adjuvant alone.

III.2. Experimental Design III.2.1. Treatment/Group (Table 4)

36 Young outbred adult male ferrets (Mustela putorius furo) (6ferrets/group) aged approximately 8 months (body weights 0.8-1.5 kg)were injected intramuscularly on days 0 and 21 with a full human dose(500 μl vaccine dose). Four groups of ferrets (n=6) were immunised withfour different concentrations of A/Vietnam/1194/2004 (NIBRG-14) (15,5.0, 1.7 and 0.6 μg HA) in combination with AS03 (standard human dose,250 μl/dose). Two control groups consisted of placebo- and AS03-treatedanimals. Sera were collected on day 21 and 42 for analysis ofserological responses. Antibody titres to homologous virus weredetermined by hemagglutination inhibition assay (HI titers). On day 49all animals were challenged by the intranasal route with a dose of 10⁵TCID₅₀ of homotypic strain A/Vietnam/1194/04. During the course ofchallenge, nasal, throat and rectal swabs were collected to assess virusshedding. After necropsy, cranioventral, craniodorsal, caudoventral andcaudodorsal sections of the right lung from each animal were weighed andstored at −80° C. until analysis. Viral titers were determined by meansof H5N1-specific TaqMan™ PCR and virus titration culture on MDCK cells.Data were expressed as Control Dilution Units (CDU) and TCID₅₀ per gramof lung tissue or per ml of swab respectively. CDU are determined from astandard curve produced from a stock of virus which is serially diluted,with each dilution undergoing nucleic acid extraction and Taqman™ PCRamplification in the same manner as test samples.

TABLE 4 Antigen +/− Group adjuvant Dosage Route/schedule Other treatment1 PBS IM Challenge H5N1 Days 0 and 21 (A/Vietnam/1194/04) Day 49 2 H5N1AS03  15 μg HA IM Challenge H5N1 Days 0 and 21 (A/Vietnam/1194/04) Day49 3 H5N1 AS03   5 μg HA IM Challenge H5N1 Days 0 and 21(A/Vietnam/1194/04) Day 49 4 H5N1 AS03 1.7 μg HA IM Challenge H5N1 Days0 and 21 (A/Vietnam/1194/04) Day 49 5 H5N1 AS03 0.6 μg HA IM ChallengeH5N1 Days 0 and 21 (A/Vietnam/1194/04) Day 49 6 AS03 alone IM ChallengeH5N1 Days 0 and 21 (A/Vietnam/1194/04) Day 49

III.2.2. Preparation of the Vaccine Formulations

III.2.2.2. Split H5N1 Adjuvanted with the Oil-in-Water Emulsion AdjuvantAS03A in a 500 μl DoseVersion 1 (Used for the Study Reported in this Example)

Preparation of one liter of Final Bulk Buffer (PBS pH 7.2±0.2): to 0.800l of water for injection, add NaCl 7.699 g, KCl 0.200 g, MgCl₂×6H₂O0.100 g, Na₂HPO₄×12H₂O 2.600 g, KH₂PO₄ 0.373 g. After solubilization,adjust to 1.0 L with water for injection.

Thiomersal TWEEN™ 80 (quantities taking into account theirconcentrations in the strain) and Triton X100 are added to the FinalBulk Buffer. This mixture is called the premixed buffer. The finalconcentration of Thiomersal is 10 μg/ml. HA to detergent ratios are 0.13for TWEEN™ 80 and 0.86 for TRITON™ X100 respectively. The day of theimmunizations 15-5-1.7 or 0.6 μg of HA (H5N1 strain) are added to thepremixed buffer. After 30 minutes stirring, 250 μl of SB62 emulsion isadded. The formulation is stirred for 30 minutes. Injections occurwithin the hour following the end of the formulation.

Version 2

Alternatively, the formulation is prepared as follows. TWEEN™ 80,TRITON™ X100 and Thiomersalare added to the Final Bulk Buffer inquantities taking into account their concentrations in the strain. After5 min stirring, 15-5-1.7 or 0.6 μg of H5N1 strain are added. After 30minutes stirring, 250 μl of SB62 emulsion is added. The formulation isstirred for 30 minutes. Injections occur within the hour following theend of the formulation.

III.2.2.3. AS03A in a 500 μl Dose (Group 6)

Version 1 (Used for the Study Reported in this Example)

250 μl SB62 emulsion is mixed with 250 μl PBS pH6.8, stirred for 5minutes and stored at 4° C. until its administration.

Version 2

Alternatively the formulation can be prepared as follows. 250 μl SB62emulsion is mixed with 250 μl PBS pH6.8 and stirred for 5 minutes.Injections occur within the hour following the end of the formulation.

Remark: In each formulation, Final Bulk Buffer is used to reachisotonicity.

III.2.3. Read-Outs (Table 5)

TABLE 5 Readout Timepoint Analysis method Protection D + 5 Postchallenge % protection (number of ferrets alive/total number ferrets pergroup) HI titers Day 42 Hemagglutination inhibition assay NeutralizingDay 42 Neutralization assay antibody titers Viral shedding Day 49 to Day54 Virus titration culture on MDCK or by Taq-Man PCR for throat swabsand lung tissue Telemetry Day 49 to Day 54 Body temperature

III.3. Results and Conclusions

Table 6 summarizes the protection data, HI titers and viral load in lungtissue and pharyngeal swabs obtained in ferrets after challenge with ahomologous H5N1 strain.

TABLE 6 Protection of AS03-adjuvanted H5N1-vaccinated ferrets againstchallenge with homologous H5N1 influenza viruses. Viral load No. dead/(No./Total no.)^(c) total no. Lung Pharyngeal (% HI tissue swabsVaccination regimen protection)^(a) titers^(b) (%) (%) PBS 4/5 (20) −5/5 (100) 5/5 (100) AS03 alone 6/6 (0) − 6/6 (100) 6/6 (100)AS03-adjuvanted H5N1 2/6 (67) + 4/6 (67) 2/6 (33) (0.6 μg)AS03-adjuvanted H5N1 1/5 (80) + 1/5 (20) 1/5 (20) (1.7 μg)AS03-adjuvanted H5N1 0/6 (100) +++ 2/6 (33) 2/6 (33) (5 μg)AS03-adjuvanted H5N1 0/6 (100) +++ 1/6 (17) 1/6 (17) (15 μg) ^(a)Oneanimal immunized with PBS and one immunized with 1.7 μg HA of theadjuvanted vaccine were euthanized during the course of vaccination (day25). There was no apparent link between vaccination and thesemortalities. ^(b)Geometric mean HI titers (D42): +++ (>160), ++(60-160) + (40-60), − (<40). ^(c)Numbers of animals with viral loaddetermined by viral culture >10² TCI D₅₀ per g tissue or per ml swab.

III.3.1. Protection Data

Before the challenge with H5N1, two animals were euthanized. One animalimmunized with PBS was euthanized because of excessive weight lossduring the course of vaccination (day 14). One animal immunized with 1.7μg HA of the adjuvanted vaccine was euthanized because of excessiveweight loss during the course of vaccination (day 25). There was noapparent link between vaccination and these mortalities.

Challenge with A/Vietnam/1194/04 in ferrets vaccinated withAS03-adjuvanted H5N1 vaccines showed an antigen dose-dependentprotection or survival curve (Table 6). All animals immunized with 5 or15 μg HA of the AS03-adjuvanted vaccine were protected against thelethal challenge. Importantly, mean HI titers against homologousA/Vietnam/1194/2004 virus were >40 in all groups of ferrets immunizedwith AS03-adjuvanted vaccines, including in the groups having receivedthe lowest doses, with 66.67 and 80.00% protection obtained against thehomologous challenge in ferrets immunized with 0.6 and 1.7 μg H5N1 splitvaccine adjuvanted with AS03, respectively. All ferrets immunized withPBS or the adjuvant alone exhibited a viral load above 10⁵ TCID₅₀/g oflung tissue and all animals shed high levels of virus in the upperrespiratory tract (throat and nasal swabs) throughout the course ofinfection. Conversely, in 65% and 75% of animals, the administration ofAS03-adjuvanted vaccines reduced the virus load below a threshold of 10²TCID₅₀ per gram of lung tissue or per ml fluid from pharyngeal swabs,respectively (Table 6) demonstrating a reduced risk of viraltransmission in ferrets receiving the AS03-adjuvanted vaccines. Only oneor two ferrets per group immunized with AS03-adjuvanted vaccines hadmoderate to high viral loads (>10² TCID₅₀). Importantly, it should benoted that most animals from placebo (PBS) and adjuvant only groups diedor were euthanized on days 2 and 3, while most animals in the vaccinatedgroups survived through to euthanasia on day 5. Consequently viral loadswere not measured on the same day post challenge for all animals.

A statistical analysis performed on these data before the challenge ledto the following conclusions:

-   -   all vaccine doses were statistically different from controls    -   P values (Fischer's exact test) were ranging from 0.0276 for        lowest dose to 0.0006 for highest dose    -   the estimated dose to induce 90% protection was estimated in        this model to be 2.9 μg    -   the lowest dose to induce 100% protection was estimated in this        model to be between 2.9 and 5 μg.

III.3.2. Humoral Responses (HI Titers)

The humoral immune response to vaccination was measured after eachimmunization on days 21 and 42. Serum samples were tested by thehemagglutination inhibition (HI) test using horse erythrocytes. Resultsare presented in Table 6.

AS03 adjuvanted monovalent H5N1 split formulations induced the strongestHI responses to the homologous strain compared to ferrets immunized withPBS or AS03 alone. An antigen dose effect was observed with the highestHI titers obtained in ferrets immunized with the dose highest antigendoses (15 or 5 μg HA of the adjuvanted vaccine) compared to lower immuneresponse in ferrets receiving the two lowest doses (1.7 or 0.8 μg HA ofthe adjuvanted vaccine).

As shown in Table 6 and FIG. 2A, a correlation was found between the HItiters and the protection in ferrets challenge with A/Vietnam H5N1. HItiters higher than 40 seemed to correlate with protection in ferretsimmunized with H5N1 split vaccines adjuvanted with AS03.

III.3.3. Humoral Responses (Neutralizing Antibody Titers)

The humoral immune response to vaccination was also tested byneutralization assay after each immunization on days 21 and 42. Resultsare presented in FIG. 3.

AS03 adjuvanted monovalent H5N1 split formulations induced the strongestneutralizing antibody responses to the homologous strain compared toferrets immunized with PBS or AS03 alone. No antigen dose effect wasobserved, with the highest neutralizing antibody responses obtained inferrets immunized with 1.7 μg of the AS03-adjuvanted H5N1 vaccine.

III.3.4. Viral Shedding after A/Vietnam H5N1 Homologous Challenge

Viral shedding was performed by viral culture and TagMan™ PCR on lungtissue and nasal/throat/rectal swabs.

As shown in Table 6, protection was also observed in terms of reductionof viral load in lung tissues and pharyngeal swabs in ferrets immunizedwith AS03-adjuvanted H5N1 split vaccines (most animal below 10² TCID₅₀per gram of tissue or per ml of swab). All ferrets immunized with PBS orthe adjuvant alone exhibited high viral load in lung tissues and in thepharynx throughout the course of infection.

FIG. 2B shows mean viral load determined both by PCR and viral culturein each group. This demonstrated that all groups receiving adjuvantedvaccine tended to exhibit reduced viral loads relative to the controlgroups receiving PBS or the adjuvant alone, with ferrets immunized with0.7 μg HA of the adjuvanted vaccine showing a more modest reduction inviral load. Little difference could be seen between ferrets immunizedwith 1.6, 5 or 15 μg HA of the adjuvanted vaccine. Finally, for theviral load in lungs, PCR results were consistent with the virustitration.

Moreover, viral shedding in nasal and rectal swabs, as well as in plasmawas investigated by viral culture and PCR. Generally, virus titrationwas less sensitive than PCR analysis. This analysis showed the presenceof H5N1 virus into the nasal cavity and rectal swabs of 2/5 ferretsreceiving PBS. In this group, 1/5 animal also shed virus in the serum.No animals immunized with AS03-adjuvanted H5N1 split vaccine shed virusin rectal swabs or plasma. Interestingly, the analyze of each individualferrets showed that some protected ferrets had high viral load and lowHI titers, demonstrating that the mechanism by which the protection wasachieved may but due, at least in part, to the induction of cellularimmunity (not evaluated in this experiment).

III.3.5. Body Temperature

Body temperatures of all animals were registered. No changes in bodytemperatures were observed during the vaccination phase. Challenge withA/Vietnam/1194/04 induced onset of fever with body temperatures rangingfrom 40° C. to 42° C. with peaks between 12 to 24 hours after start ofchallenge. During the course of infection body temperatures decreased tonormal levels in animals which survived the challenge. Animals whichdied before Day 5 showed a rapid decrease in body temperature after thepeak of fever.

In summary, serological testing indicated that significantly higher HItitres were obtained in animals immunized with adjuvanted vaccinescompared to animals immunized with PBS or the adjuvant alone. Challengewith the homologous A/Vietnam/1194/04 virus showed an antigen-dosedependent survival curve with reduced viral load in lung tissue andpharyngeal swabs from the groups receiving adjuvanted vaccines comparedto control groups. All animals in control groups (immunized with PBS orthe adjuvant alone) shed virus into the upper respiratory tract with aviral load above 10⁵ TCID₅₀/g of lung, while in groups receivingadjuvanted vaccines, only a proportion of animals shed virus into theupper respiratory tract (4/17 with 10⁵ to 10⁷ TCID₅₀/g lung tissue.majority below 10² TCID₅₀ per gram of lung or per ml of pharyngealswabs). Furthermore, there were reduced viral titres in lung tissue fromthe groups receiving adjuvanted vaccines, as compared to placebo andadjuvant only treated groups. This reduction was partially antigen dosedependent, reaching an apparent plateau at 5 μg antigen.

Example IV—Clinical Trial in an Adult Population Aged in Adults AgedBetween 18 and 60 Years with a Vaccine Containing a Split InfluenzaAntigen Preparation and AS03 Adjuvant IV.1. Introduction

A phase I, observer-blind, randomized study has been conducted in anadult population aged 18 to 60 years in 2006 in order to evaluate thereactogenicity and the immunogenicity of a pandemic influenza candidateadministered at different antigen doses (3.8 μg, 7.5 μg, 15 μg and 30 μgHA) adjuvanted or not with the adjuvant AS03. The humoral immuneresponse (i.e., anti-hemagglutinin, neutralising and anti-neuraminidaseantibody titres) and cell mediated immune response (CD4 and/or CD8 Tcell responses) are measured 21 days after each of the two intramuscularadministration of the candidate vaccine formulations. The non-adjuvantedgroups served as reference for the respective adjuvanted group receivingthe same antigen content.

IV.2. Study Design

The plan was for eight groups of 50 subjects each to receive in parallelthe following vaccine intramuscularly. In the trial however the groupswere split as follows:

-   -   one group of 50 subjects received two administrations of the        pandemic split virus influenza vaccine containing 3.8 μg HA    -   one group of 51 subjects received two administrations of the        pandemic split virus influenza vaccine containing 3.8 μg HA and        adjuvanted with AS03    -   one group of 50 subjects received two administrations of the        pandemic split virus influenza vaccine containing 7.5 μg HA    -   one group of 50 subjects received two administrations of the        pandemic split virus influenza vaccine containing 7.5 μg HA and        adjuvanted with AS03    -   one group of 50 subjects received two administrations of the        pandemic split virus influenza vaccine containing 15 μg HA    -   one group of 50 subjects received two administrations of the        pandemic split virus influenza vaccine containing 15 μg HA and        adjuvanted with AS03    -   one group of 50 subjects received two administrations of the        pandemic split virus influenza vaccine containing 30 μg HA    -   one group of 49 subjects received two administrations of the        pandemic split virus influenza vaccine containing 30 μg HA and        adjuvanted with AS03

The enrolment was performed to ensure that half of subjects from eachgroup will be aged between 18 and 30 years.

Vaccination schedule: two injection of pandemic influenza candidatevaccine at day 0 and day 21, blood sample collection, read-out analysisat day 21 and 42 (HI antibody determination, NI antibody determination,determination of neutralising antibodies, and CMI analysis), studyconclusion (day 51) and study end (180 days).

IV.3. Study Objectives IV.3.1. Primary Objectives

-   -   To evaluate the humoral immune response induced by the study        vaccines in term of anti-haemagglutinin antibody titers.    -   To evaluate the safety and reactogenicity of the study vaccines        in term of solicited local and general adverse events,        unsolicited adverse events and serious adverse events.

For the Humoral Immune Response:

Observed variables at days 0, 21, 42 and 180: serumHeamagglutination-inhibition antibody titers.Derived Variables (with 95% Confidence Intervals):

-   -   Geometric mean titers (GMTs) of serum antibodies at days 0, 21,        42 and 180    -   Seroconversion rates* at days 21, 42 and 180    -   Conversion factors** at days 21, 42 and 180    -   Seroprotection rates*** at days 0, 21, 42 and 180        * Seroconversion rate for Haemagglutinin antibody response is        defined as the percentage of vaccinees who have either a        prevaccination titer <1:10 and a post-vaccination titer ≥1:40 or        a prevaccination titer ≥1:10 and at least a fourfold increase in        post-vaccination titer        **Conversion factor defined as the fold increase in serum HI        GMTs post-vaccination compared to day 0;        ***Seroprotection rate defined as the percentage of vaccinees        with a serum HI titer after vaccination that usually is accepted        as indicating protection.

For the Safety/Reactogenicity Evaluation:

-   1. Percentage, intensity and relationship to vaccination of    solicited local and general signs and symptoms during a 7 day    follow-up period (i.e., day of vaccination and 6 subsequent days)    after each vaccination and overall.-   2. Percentage, intensity and relationship to vaccination of    unsolicited local and general signs and symptoms during a 21 days    follow-up period after the first vaccination, during 30 days    follow-up period after the second vaccination and overall.

Occurrence of serious adverse events during the entire study.

IV.3.2. Secondary Objectives

-   -   To evaluate the humoral immune response induced by the study        vaccines in term of serum neutralizing antibody titers    -   To evaluate the cell-mediated immune response induced by the        study vaccines in term of frequency of influenza-specific        CD4/CD8 T lymphocytes

In addition, the impact of vaccination on Influenza-specific memory Bcells using the Elispot technology will be evaluated.

For the Humoral Immune Response:

Observed variables at days 0, 21, 42 and 180: serum neutralizingantibody titers.Derived Variables (with 95% Confidence Intervals):

-   -   Geometric mean titers (GMTs) of serum antibodies at days 0, 21,        42 and 180    -   Seroconversion rates* at day s21, 42 and 180        * Seroconversion rate for Neutralising antibody response is        defined as the percentage of vaccinees with a minimum 4-fold        increase in titer at post-vaccination.

For the CMI Response:

-   1. Frequency of cytokine CD4/CD8 cells per 10⁶ in tests producing at    least two different cytokines (CD40L, IL-2, TNF-α, IFN-γ)-   2. Frequency of cytokine-positive CD4/CD8 cells per 10⁶ in tests    producing at least CD40L and another signal molecule (IL-2, IFN-γ,    TNF-α)-   3. Frequency of cytokine-positive CD4/CD8 cells per 10⁶ in tests    producing at least IL-2 and another signal molecule (CD40L, IFN-γ,    TNF-α)-   4. Frequency of cytokine-positive CD4/CD8 cells per 10⁶ in tests    producing at least TNF-α and another signal molecule (IL-2, IFN-γ,    CD40L)

Frequency of cytokine-positive CD4/CD8 cells per 10⁶ in tests producingat least IFN-γ and another signal molecule (CD40L, IL-2, TNF-α).

At days 0, 21, 42 and 180: frequency of influenza-specific memory Bcells per 10⁶ cells in test.

IV.4. Vaccine Composition and Administration (Table 7) IV.4.1. VaccinePreparation IV.4.1.1. Composition of AS03 Adjuvanted Influenza Vaccine

AS03 contains the oil-in-water SB62 emulsion, consisting of an oil phasecontaining DL-α-tocopherol and squalene, and an aqueous phase containingthe non-ionic detergent polysorbate 80.

The active substance of the pandemic influenza vaccine candidate is aformaldehyde inactivated split virus antigen derived from the vaccinevirus strain A/VietNam/1194/2004 (H5N1) NIBRG-14. The dose of HA antigenis ranging from 3.8 to 30 μg per dose. The split virus monovalent bulksused to produce the AS03 adjuvanted influenza vaccine are manufacturedfollowing the same procedure as used for GSK Biologicals licensedinterpandemic influenza vaccine Fluarix™/α-Rix. For the purpose of thisclinical trial the virus strain used to manufacture the clinical lots isthe H5N1 vaccine strain A/Vietnam/1194/04-clade 1 NIBRG-14 recombinantH5N1 prototype vaccine strain derived from the highly pathogenicA/Vietnam/1194/04. This recombinant prototype strain has been developedby NIBSC using reverse genetics (a suitable reference is Nicolson et al.2005, Vaccine, 23, 2943-2952)). The reassortant strain combines the H5and N1 segments to the A/PR/8/34 strain backbone, and the H5 wasengineered to eliminate the polybasic stretch of amino-acids at the HAcleavage site that is responsible for high virulence of the originalstrains. This was achieved by transfecting Vero cells with plasmidscontaining the HA gene (modified to remove the high pathogenicitydeterminants) and NA gene of the human isolate A/VietNam/1194/2004(H5N1) and plasmids containing the internal genes of PR8. The rescuedvirus was passaged twice on eggs and was then designated as thereference virus NIBRG-14. The attenuated character of this H5N1reassortant was extensively documented in a preclinical safetyassessment (performed by NIBSC), as is also done routinely for theclassical flu vaccine strains.

The AS03-adjuvanted pandemic influenza candidate vaccine according tothe invention is a 2 component vaccine consisting of 0.5 ml ofconcentrated inactivated split virion antigens presented in a type Iglass vial and of a pre-filled type I glass syringe containing 0.5 ml ofthe AS03 adjuvant. At the time of injection, the content of theprefilled syringe containing the adjuvant is injected into the vial thatcontains the concentrated inactivated split virion antigens. Aftermixing the content is withdrawn into the syringe and the needle isreplaced by an intramuscular needle. One dose of the reconstituted theAS03-adjuvanted influenza candidate vaccine corresponds to 1 ml. Eachvaccine dose of 1 ml contains 3.8 μg, 7.5 μg, 15 μg or 30 μghaemagglutinin (HA) or any suitable HA amount which would have bedetermined such that the vaccine meets the efficacy criteria as detailedherein.

Alternatively, the AS03-adjuvanted pandemic influenza candidate vaccineaccording to the invention is a 2 component vaccine consisting of 0.25ml of concentrated inactivated split virion antigens presented in a typeI glass vial and of a pre-filled type I glass syringe containing 0.25 mlof the AS03 adjuvant. At the time of injection, the content of theprefilled syringe containing the adjuvant is injected into the vial thatcontains the concentrated inactivated split virion antigens. Aftermixing the content is withdrawn into the syringe and the needle isreplaced by an intramuscular needle. One dose of the reconstituted theAS03-adjuvanted influenza candidate vaccine corresponds to 1 ml. Eachvaccine dose of 1 ml contains 3.8 μg, 7.5 μg, 15 μg or 30 μghaemagglutinin (HA) or any suitable HA amount which would have bedetermined such that the vaccine meets the efficacy criteria as detailedherein.

The vaccine excipients are polysorbate 80 (TWEEN™ 80), octoxynol 10(TRITON™ X-100), sodium chloride, disodium hydrogen phosphate, potassiumdihydrogen phosphate, potassium chloride, magnesium chloride hexahydrateand water for injection. Thiomersal has been added as an antimicrobialpreservative to prevent contamination during use, since it isanticipated that when a pandemic occurs the main presentation will bepresented in a multidose container (vials or ampoules), for which apreservative is required. For this reason, the pandemic vaccine isformulated with thiomersal at 5 μg/dose as preservative. Suitably thepandemic vaccine may be formulated with thiomersal at 10 μg/dose aspreservative or a slightly higher dose, such as up to 25 μg/dose ofvaccine.

IV.4.1.2. Production of Split Inactivated Influenza H5N1 AntigenPreparation

The virus monobulks are prepared by growing H5N1 working seed inembryonated hen's eggs. The manufacturing process for the monovalentbulks of split, inactivated influenza H5N1 strain, illustrated in FIG.4, is identical to the manufacturing process for the monovalent bulks ofα-Rix™.

Basically, the manufacturing process of the monovalent bulks can bedivided in four main parts:

1) Propagation of the working seed in fertilized hen's eggs, harvestingand pooling of infected allantoic fluids so as to obtain the “crudemonovalent whole virus bulk” (step 1).2) Purification of each virus strain leading to the “purified monovalentwhole virus bulk” (steps 2-6).3) Splitting of the purified monovalent whole virus bulk with sodiumdeoxycholate resulting in the “purified monovalent split virus bulk”(steps 7-8/1).4) Inactivation of the purified monovalent split virus bulk in two stepsby incubation with sodium deoxycholate and with formaldehyde, followedby ultrafiltration and sterile filtration, in order to obtain the“purified monovalent inactivated split virus bulk”, or “Monovalent Bulk”(steps 8/2-9).

1) Production of Crude Monovalent Whole Virus Bulk Preparation of theVirus Inoculum:

On the day of inoculation of the embryonated eggs, an inoculum isprepared by mixing the working virus seed lot with phosphate buffercontaining 25 μg/mL hydrocortisone, and 0.5 mg/mL gentamicin sulfate.The virus inoculum is kept at room temperature until the inoculation.

Inoculation of Embryonated Eggs:

Eleven day-old pre-incubated embryonated eggs are used for virusreplication. The eggs are transferred into the production rooms afterformaldehyde fumigation of the shells. Approximately 120,000 eggs areinoculated with 0.2 mL of the virus inoculum each using an automatic egginoculation apparatus. The inoculated eggs are incubated at 34.0° C. for72 hours.

At the end of the incubation period, the eggs are inspected visually forthe presence of living embryo and age-adequate blood vessels. Theembryos are killed by cooling the eggs and stored for 12-46 hours at2-8° C. Alternatively the killed embryos may be stored for 13.5 hours at2-10° C.

Harvest

The allantoic fluid (approximately 12 mL) from the chilled embryonatedeggs is harvested by egg harvesting machines. The allantoic fluids arecollected in a stainless steel tank thermo-regulated at 2-8° C. At thisstage the product is called the “crude monovalent whole virus bulk”. Thecrude monovalent whole virus bulk is not stored but immediatelytransferred to the clarification step.

2) Production of Purified Monovalent Whole Virus Bulk

All operations are performed at 2-8° C., until the flow throughultracentrifugation, which is performed at room temperature.

Clarification:

The harvested allantoic fluid is clarified by continuous moderate speedcentrifugation. This step removes big particles that could have beencollected during the harvest of the allantoic fluid (e.g. parts of eggshells).

Adsorption Step:

This step permits to clarify further the allantoic fluid through aprecipitation of virus material, by adsorption to a dibasic calciumhydrogen phosphate gel.

To obtain the dibasic calcium hydrogen phosphate (CaHPO₄) gel, 0.5 mol/Ldisodium hydrogen phosphate (Na₂HPO₄) and 0.5 mol/L calcium chloride(CaCl₂) are added to the clarified virus pool to reach a finalconcentration of 1.87 g CaHPO₄ per L.

After sedimentation for at least 8 hours to maximum 36 hours, thesupernatant is removed and the sediment containing the influenza virusesis re-solubilized by the addition of an 8.7% disodium EDTA solution.

Filtration:

The resuspended influenza sediment is filtered through a 6-μm filtermembrane to remove potential remaining pellets.

Flow Through Ultracentrifugation:

The influenza virus is further purified (removal of proteins andphospholipids) and concentrated by isopycnic ultracentrifugation in alinear sucrose gradient (0-55%) at a flow rate of 8-20 liters per hour.The gradient is formed using the sucrose solution 55% (w/w) with 0.01%thimerosal, and a Phosphate buffer pH 7.4 with 0.01% thimerosal. This isdone in the presence of 100±15 μg/mL thiomersalin order to control theprocess bioburden, as the centrifugation is performed at roomtemperature.

Four different fractions are recovered by measuring the sucroseconcentration via a refractometer:

-   -   Fraction 4/1: 55-47% sucrose    -   Fraction 4/2: 47-38% sucrose    -   Fraction 4/3: 38-20% sucrose    -   Fraction 4/4: 20-0% sucrose

The upper limit of fraction 4/2 is selected to balance between a highpurity coefficient HA/protein and a maximum recovery of whole virus. Thelimit between fractions 4/2 and 4/3 is selected to minimize theovalbumin content in fraction 4/2. The lower limit of fraction 4/3 isselected on the basis of the HA content found in the low sucrosegradient range. Fractions 4/2 and 4/3 are used for further preparations.Most of the virus is collected in Fraction 4/2. Fraction 4/3, whichcontains both virus and proteins, is further purified. First, thesucrose concentration of Fraction 4/3 is reduced below 6% (necessary forthe subsequent centrifugation step) by ultrafiltration. Then, Fraction4/3 is pelleted via centrifugation to remove any soluble contaminants(proteins). The pellet is re-suspended in phosphate buffer pH 7.4 andthoroughly mixed to obtain a homogeneous suspension. The holding timesare maximum 36 hours for Fraction 4/3, maximum 60 hours for Fraction 4/2and maximum 36 hours for the purified Fraction 4/3.

Dilution

Both fractions, the treated Fraction 4/3 and untreated Fraction 4/2, arepooled and diluted by adding 60 L of phosphate buffer pH 7.4.

At this stage, the pool of material corresponds to the “purifiedmonovalent whole virus bulk”.

3) Preparation of the Purified Monovalent Split Virus Bulk Flow ThroughUltracentrifugation in the Presence of Sodium Deoxycholate:

The influenza virus is splitted and further purified by centrifugationthrough a linear sucrose gradient (0-55%—formed with sucrose solutionS8a and buffer S6a) that contains 1.5% sodium deoxycholate. TWEEN™-80 ispresent at 0.1% in the gradient. The virus is processed at a rate of 8liters per hour. At the end of the centrifugation, three differentfractions are collected. The range of the main fraction (Fraction 7/2)is selected based on strain-dependent validation of splittingconditions, with as objective to collect a fraction consisting ofpredominantly disrupted influenza virus antigen, while minimizing asmuch as possible remaining whole virus particles and phospholipidscoming from the virus membrane after splitting.

For A/Vietnam/1194/2004 NIBRG-145 the range of fraction 7/2 is set at20-41% sucrose. The haemagglutinin antigen is concentrated in Fraction7/2, which contains approximately 1.2% sodium deoxycholate. Thismaterial corresponds to the “purified monovalent split virus bulk”.

4) Preparation of the Purified Final Monovalent Split, Inactivated VirusBulk Filtration:

Fraction 7/2 is diluted threefold in phosphate buffer S7c, whichcontains 0.025% TWEEN™-80. Then, fraction 7/2 is gradually filtered downto a 0.45 μm filter membrane, briefly sonicated (to facilitatefiltration) and filtered through a 0.2 μm membrane. At the end of thefiltration, the filters are rinsed with phosphate buffer (S107c)containing 0.025% TWEEN™-80. As a result of the filtration and rinsing,the final volume of the filtrate is 5 times the original fraction 7/2volume.

Sodium Deoxycholate Inactivation:

The resulting solution is incubated at 22±2° C. for at least 84 hours.

After completion of the first inactivation step, the material is dilutedwith phosphate buffer S7c to reduce the total protein content to acalculated concentration of 500 μg/mL:

Formaldehyde Inactivation:

Formaldehyde is added to a calculated final concentration of 100 μg/mL.Inactivation takes place in a single use low density polyethylene 100 Lbag at 20±2° C. for at least 72 hours.

Ultrafiltration:

The inactivated split virus material is ultrafiltered through membraneswith a molecular weight cut off of 30,000 Dalton, using consecutivelybuffers S7b and S1b

After a volume reduction, the volume remains constant duringultrafiltration (diafiltration) by adding phosphate buffer and phosphatebuffered saline (S1 b) containing 0.01% TWEEN™-80.

During ultrafiltration, the content of formaldehyde, NaDoc and sucroseis reduced. The material is concentrated to 15-25 liters and istransferred immediately to the final filtration step.

Sterile Filtration:

After ultrafiltration, the split inactivated material is graduallyfiltered down to a 0.2 μm membrane.

The final sterile filtration through a 0.22 μm sterile grade membrane isperformed in a Class 100 environment. At the end of the filtration thefilters are rinsed with phosphate buffered saline solution S1b,containing 0.01% TWEEN™-80. Herewith, the filtrate is diluted to aprotein concentration less than 1000 μg/mL, to avoid aggregation duringsubsequent storage.

The resulting material is the “purified monovalent inactivated splitvirus bulk” or “monovalent bulk”.

Storage:

The final monovalent bulks of split inactivated influenza H5N1 virusesare stored at 2-8° C. for a maximum of 18 months in Type I glassbottles.

IV.4.1.3. Preparation of the Vaccine Compositions with AS03 AdjuvantedH5N1

1) Composition

The AS03 adjuvanted inactivated split virus pandemic influenza candidatevaccine to be evaluated in the phase I clinical trial H5N1-007 isintended for intramuscular administration. The vaccine is a 2 componentvaccine consisting of 2× concentrated inactivated split virion (H5N1)antigens presented in a type I glass vial, and of the AS03 adjuvantcontained in a pre-filled type I glass syringe.

One dose of reconstituted AS03-adjuvanted pandemic influenza vaccinecorresponds to 1 ml. The composition is given in Table 7. Since studyH5N1-007 is a dose finding study, the HA content per dose is differentfor each of the clinical lots to be tested. One dose contains 3.8, 7.5,15 or 30 μg HA. The vaccine contains the following residuals from themanufacturing process of the drug substance: formaldehyde, ovalbumin,sucrose, thiomersal and sodium deoxycholate.

TABLE 7 Composition of the reconstituted AS03 adjuvanted pandemicinfluenza candidate vaccine Component Quantity per dose ActiveIngredients Inactivated split virions 30/15/7.5/3.8 μg HAA/VietNam/1194/2004 NIBRG-14 (H5N1) AS03 Adjuvant SB62 emulsion squalene10.68 mg DL-α-tocopherol 11.86 mg Polysorbate 80 (TWEEN ™ 80)  4.85 mgExcipients Polysorbate 80 (TWEEN ™ 80)¹ 12.26 μg/μg HA Octoxynol 10(TRITONT ™ X-100)²  1.16 μg/μg HA Thiomersal    5 μg Sodium chloride 7.5 mg Disodium hydrogen phosphate    1 mg Potassium dihydrogenphosphate  0.36 mg Potassium chloride  0.19 mg Magnesium chloride 23.27μg

2) Formulation

The manufacturing of the AS03-adjuvanted pandemic influenza vaccineconsists of three main steps:

-   (a) Formulation of the split virus final bulk (2× concentrated)    without adjuvant and filling in the antigen container-   (b) Preparation of the AS03 adjuvant and filling in the adjuvant    container-   (c) Extemporaneous reconstitution of the AS03 adjuvanted split virus    vaccine    1) Formulation of the Final Bulk without Adjuvant and Filling in the    Antigen Container.

The formulation flow diagram is presented in FIG. 5.

The volume of the monovalent bulk is based on the HA content measured inthe monovalent bulk prior to the formulation and on a target volume of4000 ml.

The final bulk buffer (Formulation buffer comprising: Sodium chloride:7.699 g/l; Disodium phosphate dodecahydrate: 2.600 g/l; Potassiumdihydrogen phosphate: 0.373 g/l; potassium chloride: 0.2 g/l; Magnesiumchloride hexahydrate: 0.1 g/l) and the correct volumes of TRITON™ X-100(5% Octoxynol 10 (TRITON™ X-100) solution) and thiomersal (0.9%Thiomersalstock solution) taking into account any residual thiomersalfrom the antigen preparation, are mixed together under continuousstirring. The monobulk H5N1 is then diluted in the resulting bulkbuffer—TRITON™ X-100-thiomersal in order to have a final concentrationof 60/30/15/7.6 μg H5N1 per ml of final bulk per ml (30, 15, 7.5 or 3.8μg HA/500 μl final bulk). The mixture is stirred during 30-60 minutes.The pH is checked to be at 7.2±0.3. There was no need to add TWEEN™ 80because the concentration of TWEEN™ 80 (822 μg/ml) present in themonobulk was sufficient to reach the concentration target (12.26 μg/μgHA).

The final bulk is aseptically filled into 3-ml sterile Type I (Ph. Eur.)glass vials. Each vial contains a volume of 0.65 ml±0.05 ml.

2) Preparation of the AS03 Sterile Adjuvant Bulk and Filling in theAdjuvant Container.

The adjuvant AS03 is prepared by mixing of two components: SB62 emulsionand phosphate buffer.

SB62 Emulsion

The preparation of the SB62 emulsion is realised by mixing under strongagitation of an oil phase composed of hydrophobic components(α-tocopherol and squalene) and an aqueous phase containing the watersoluble components (TWEEN™ 80 and phosphate-saline buffer at pH 6.8).While stirring, the oil phase (1/10 total volume) is transferred to theaqueous phase (9/10 total volume), and the mixture is stirred for 15minutes at room temperature. The resulting mixture then subjected toshear, impact and cavitation forces in the interaction chamber of amicrofluidizer (15000 PSI—8 cycles) to produce submicron droplets(distribution between 100 and 200 nm). The resulting pH is between6.8±0.1. The SB62 emulsion is then sterilised by filtration through a0.22 μm membrane and the sterile bulk emulsion is stored refrigerated inCupac containers at 2 to 8° C. Sterile inert gas (nitrogen) is flushedinto the dead volume of the SB62 emulsion final bulk container for atleast 15 seconds.

The final composition of the SB62 emulsion is as follows (Table 8):

TABLE 8 TWEEN ™ 80: 1.8% (v/v) 19.4 mg/ml Squalene:   5% (v/v) 42.8mg/ml α-tocopherol:   5% (v/v) 47.5 mg/ml Phosphate-saline buffer NaCl121 mM KCl 2.38 mM Na₂HPO₄ 7.14 mM KH₂PO₄ 1.3 mM pH 6.8 ± 0.1

AS03 Adjuvant System

The AS03 adjuvant system is prepared by mixing buffer (PBS mod) withSB62 bulk. The mixture is stirred for 15-45 minutes at room temperature,and the pH is adjusted to 6.8±0.1 with NAOH (0.05 or 0.5 M)/HCl (0.03 Mor 0.3 M). After another stirring for 15-20 minutes at room temperature,the pH is measured and the mixture is sterilised by filtration through a0.22 μm membrane. The sterile AS03 adjuvant is stored at +2-8° C. untilaseptical filling into 1.25-ml sterile Type I (Ph. Eur.) glass syringes.Each syringe contains a volume overage of 720 μl (500 μl+220 μloverfill)

The final composition of the AS03 adjuvant is as follows (Table 9):

TABLE 9 SB62 0.25 ml Squalene 10.68 mg Tocopherol 11.86 mg Polysorbate80 4.85 mg PBS-mod: NaCl 137 mM KCl 2.7 mM Na₂HPO₄ 8.1 mM KH₂PO₄ 1.47 mMpH 6.8 ± 0.1 Volume 0.5 ml

3) Extemporaneous Reconstitution of the AS03 Adjuvanted Split VirusVaccine.

At the time of injection, the content of the prefilled syringecontaining the adjuvant is injected into the vial that contains theconcentrated trivalent inactivated split virion antigens. After mixingthe content is withdrawn into the syringe and the needle is replaced byan intramuscular needle. One dose of the reconstituted theAS03-adjuvanted influenza candidate vaccine corresponds to 1 ml

IV.4.2 Vaccine Preparation

The vaccines were administered intramuscularly in the deltoid region ofthe non-dominant arm. The pandemic influenza candidate vaccines are 2components vaccines consisting of antigens presented in a vial (antigencontainer) and a pre-filled syringe containing either the adjuvant(adjuvant container) or the diluent. At the time of injection, thecontent of the pre-filled syringe is injected into the vial thatcontains the antigens. After mixing, the content is withdrawn into thesyringe. The used needle is replaced by an intramuscular needle. Onedose of the vaccine corresponds to 1 ml.

IV.5 Study Population Results

A total of 400 subjects were enrolled in this study: 49 to 51 subjectsin each of the 8 groups. The mean age of the total vaccinated cohort atthe time of vaccination was 34.3 years with a standard deviation of12.76 years. The mean age and gender distribution of the subjects acrossthe 8 vaccine groups was similar.

IV.6 Safety Conclusions

The administration of the pandemic influenza candidate vaccineadjuvanted with AS03 was safe and clinically well tolerated in the studypopulation, i.e., adult people aged between 18 and 60 years.

IV.7 Immunogenicity Results

Analysis of immunogenicity was performed on the ATP (According ToProtocol) cohort (394 subjects).

IV.7.1. Humoral Immune Response

In order to evaluate the humoral immune response induced by the pandemicinfluenza H5N1 candidate vaccine adjuvanted with AS03, the followingparameters (with 95% confidence intervals) were calculated for eachtreatment group:

-   -   Geometric mean titres (GMTs) of HI antibody titres at days 0, 21        and 42.    -   Seroconversion rates (SC) at days 21 and 42;    -   Conversion factors at day 21 and 42;    -   Protection rates at day 21 and 42.

IV.7.1.1 Anti-Hemagglutinin Antibody Response a) HI Geometric MeanTitres (GMT)

The GMTs for HI antibodies with 95% CI are shown in Table 10 (GMT foranti-HI antibody) and in FIG. 6. Pre-vaccination GMTs of antibodies forthe H5N1 vaccination strain were within the same range in the eightstudy groups. Following the first vaccination, in all non-adjuvantedgroups anti-haemagglutinin antibody levels increased only very modestlyin a dose dependent manner. In the adjuvanted vaccination groups, a moreprominent increase in anti-haemagglutinin antibody levels was alreadyobserved after the first vaccination, with the highest GMT in the groupreceiving the highest antigen dose (HN30AD). Post second vaccination,GMTs in the non adjuvanted groups increased slightly over the post-firstvaccination GMT. In comparison, significant higher GMTs were observedafter the second vaccination in all adjuvanted groups, with a dosedependant increase observed from the 3.8 μg to the 7.5 μg to the 15 μggroup. For the 30 μg group, a lower GMT than for the 7.5 μg group wasobserved. All adjuvanted study groups, including the lowest dose of 3.8μg HA, elicited an immune response satisfying the criteria for licensureof pandemic vaccines based on FDA draft guidance (March 2006) as well asthe criteria established by the EMEA.

TABLE 10 Geometric mean titers (GMTs) for anti-HA antibody at differenttimepoints (ATP cohort for immunogenicity) GMT 95% CI Antibody GroupTiming N value LL UL Min Max FLU A/VIET/04 AB HN30 PRE 49 5.2 4.8 5.6<10.0 28.0 PI(D21) 49 14.1 8.9 22.6 <10.0 1280.0 PII(D42) 49 20.0 12.532.1 <10.0 905.0 HN15 PRE 49 5.3 4.8 5.9 <10.0 40.0 PI(D21) 49 10.4 6.915.6 <10.0 640.0 PII(D42) 49 14.7 9.6 22.4 <10.0 640.0 HN8 PRE 49 5.05.0 5.0 <10.0 <10.0 PI(D21) 49 6.8 5.4 8.7 <10.0 160.0 PII(D42) 49 8.56.3 11.5 <10.0 160.0 HN4 PRE 50 5.0 5.0 5.0 <10.0 <10.0 PI(D21) 50 5.14.9 5.4 <10.0 20.0 PII(D42) 50 6.2 5.3 7.4 <10.0 57.0 HN30AD PRE 48 5.14.9 5.5 <10.0 20.0 PI(D21) 48 36.7 22.7 59.3 <10.0 640.0 PII(D42) 48187.5 116.2 302.7 <10.0 1280.0 HN15AD PRE 49 5.1 4.9 5.2 <10.0 10.0PI(D21) 49 24.7 14.8 41.4 <10.0 1280.0 PII(D42) 49 306.7 218.4 430.8<10.0 1810.0 HN8AD PRE 50 5.4 4.8 6.0 <10.0 40.0 PI(D21) 50 24.6 15.838.4 <10.0 640.0 PII(D42) 50 205.3 135.1 312.0 <10.0 1280.0 HN4AD PRE 505.4 4.8 6.0 <10.0 80.0 PI(D21) 50 12.9 8.9 18.7 <10.0 640.0 PII(D42) 50149.3 93.2 239.1 <10.0 1280.0 HN30 = H5N1 30 μg HN15 = H5N1 15 μg HN8 =H5N1 7.5 μg HN4 = H5N1 3.8 μg HN30AD = H5N1 30 μg + AS03 HN15AD = H5N115 μg + AS03 HN8AD = H5N1 7.5 μg + AS03 HN4AD = H5N1 3.8 μg + AS03 GMT =geometric mean antibody titre calculated on all subjects N = number ofsubjects with available results n/% = number/percentage of subjects withtitre within the specified range 95% CI = 95% confidence interval; LL =Lower Limit, UL = Upper Limit MIN/MAX = Minimum/Maximum PRE =Pre-vaccination dose 1 PI(D21) = Post-vaccination at day 21 PII(D42) =Post-vaccination at day 42 Data source = Appendix table IIIA

b) Conversion Factors of Anti-HI Antibody Titres, Seroprotection Ratesand Seroconversion Rates (Correlates for Protection as Established forInfluenza Vaccine in Humans)

Results are presented in Tables 11 (conversion factors), 12(seroprotection rates) and 13 (seroconversion rates). A strong adjuvanteffect was observed after each of the two vaccine doses.

The conversion factors (Table 11, FIG. 9) represent the fold increase inserum HI GMTs for the vaccine strain on day 21 and 42 compared to day 0.The conversion factor after the second vaccination varies from 1.2 to3.9 in the 4 non-adjuvanted groups and from 27.9 to 60.5 in theadjuvanted groups. Conversion factors in the AS03 adjuvanted groups arelargely superior to the 2.5 fold increase in GMT required by theEuropean Authorities for interpandemic vaccines for adults (set forth inTable 1). Currently, for pandemic candidate vaccines the same criteriaare applied as utilized for annual licensure of interpandemic influenzavaccine. Of note, all except the lowest antigen concentration adjuvantedgroups achieve a conversion factor of >2.5 already after the firstvaccination.

The seroprotection rates (Table 12, FIG. 8) represent the proportion ofsubjects with a serum HI titre ≥40 on day 21 and 42. Prior tovaccination, 3 of the subjects (1 in group HN15, 1 in group HN8AD and 1in group HN4D) were found to have protective levels of antibodies forvaccine strain H5N1 A/Vietnam/1194/2004. For H5N1 a very low percentageof seroprotected individuals prior to vaccination was obtained,confirming observation of previous studies (Bresson J L et al. TheLancet. 2006:367 (9523):1657-1664; Treanor J J et al. N Engl J Med.2006; 354:1343-1351). At day 21, the seroprotection rates in thenon-adjuvanted groups ranged from 0.0% to 28.6% (Table 12), while in theadjuvanted groups 26.0% to 58.3% of subjects achieved a protectivetiter. After the second dose of pandemic influenza candidate vaccine,4.0 to 42.9% of subjects in the non-adjuvanted groups and 84.0% to 95.9%in the adjuvanted groups had a titer equal or above the thresholdconsidered as protective (i.e., HI titer ≥1:40). Consequently, up to95.9% of subjects (group 15HNAD) receiving an adjuvanted pandemiccandidate vaccine had a serum HI titre ≥40 after 2 vaccinations and weredeemed to be protected against the H5N1 vaccination strain. All fouradjuvanted formulations exceeded the seroprotection rate of 70% requiredin the 18-60 year old population by the European Authorities—with asubstantial proportion of subjects already achieving a protective titerafter the first dose—while non of the non-adjuvanted candidates vaccinesreached this criterion.

The seroconversion rates (Table 13, FIG. 7) represent the percentage ofvaccinees that have either a prevaccination titer <1:10 and apost-vaccination titer ≥1:40 or a prevaccination titer ≥1:10 and atleast a fourfold increase in post-vaccination titer on day 21 and 42 ascompared to day 0. After the first vaccination, seroconversion rates inthe non-adjuvanted groups ranged from 0.0% to 14.9% (Table 13). In thecorresponding adjuvanted study groups, seroconversion rates between24.0% and 58.3% were observed after the first vaccination, exceedingalready, in 3 of the 4 adjuvanted groups receiving different antigencontents (adjuvanted formulations containing antigen doses above 7.5μg), the requirements of the EMEA (seroconversion rate greater than 40%in the 18-60 year old population required).—compared to none with thenon-adjuvanted formulations. After the second vaccination between 4.0%and 40.8% of subjects in the non-adjuvanted groups, but 82.0% to 95.9%of subjects in the adjuvanted groups either achieved a seroconversion orfour-fold increase. Therefore, after two vaccinations all fouradjuvanted formulations of the candidate vaccine fulfilled the criterionfor licensure as set by the EMEA, but only the highest dose ofnon-adjuvanted vaccine just achieved (HN30: 40.8%) this threshold.

TABLE 11 Seroconversion factor for HAI antibody titer at eachpost-vaccination time point (ATP cohort for immunogenicity) 95% CIVaccine strain Timing Group N GMR LL UL FLU A/VIET/04 AB PI(D21) HN30 492.7 1.7 4.3 HN15 49 1.9 1.3 2.8 HN8 49 1.4 1.1 1.7 HN4 50 1.0 1.0 1.1HN30AD 48 7.1 4.3 11.7 HN15AD 49 4.9 2.9 8.1 HN8AD 50 4.6 3.0 7.0 HN4AD50 2.4 1.7 3.5 PII(D42) HN30 49 3.9 2.4 6.2 HN15 49 2.8 1.9 4.1 HN8 491.7 1.3 2.3 HN4 50 1.2 1.1 1.5 HN30AD 48 36.4 22.7 58.5 HN15AD 49 60.542.8 85.5 HN8AD 50 38.1 24.8 58.4 HN4AD 50 27.9 17.2 45.2 HN30 = H5N1 30μg HN15 = H5N1 15 μg HN8 = H5N1 7.5 μg HN4 = H5N1 3.8 μg HN30AD = H5N130 μg + AS03 HN15AD = H5N1 15 μg + AS03 HN8AD = H5N1 7.5 μg + AS03 HN4AD= H5N1 3.8 μg + AS03 N = number of subjects with available results n/% =number/percentage of subjects with titre within the specified range PRE= Pre-vaccination PI(D21) = Post vaccination at day 21 PII(D42) = Postvaccination at day 42

TABLE 12 Seroprotection rates at days 0, day 21 and day 42 defined asthe percentage of vaccinees with the serum anti-HA titer ≥ 1:40 (ATPcohort for immunogenicity) ≥40 1/DIL 95% CI Antibody Group Timing N n %LL UL FLU A/VIET/04 AB HN30 PRE 49 0 0.0 0.0 7.3 PI(D21) 49 14 28.6 16.643.3 PII(D42) 49 21 42.9 28.8 57.8 HN15 PRE 49 1 2.0 0.1 10.9 PI(D21) 4910 20.4 10.2 34.3 PII(D42) 49 17 34.7 21.7 49.6 HN8 PRE 49 0 0.0 0.0 7.3PI(D21) 49 4 8.2 2.3 19.6 PII(D42) 49 8 16.3 7.3 29.7 HN4 PRE 50 0 0.00.0 7.1 PI(D21) 50 0 0.0 0.0 7.1 PII(D42) 50 2 4.0 0.5 13.7 HN30AD PRE48 0 0.0 0.0 7.4 PI(D21) 48 28 58.3 43.2 72.4 PII(D42) 48 41 85.4 72.293.9 HN15AD PRE 49 0 0.0 0.0 7.3 PI(D21) 49 24 49.0 34.4 63.7 PII(D42)49 47 95.9 86.0 99.5 HN8AD PRE 50 1 2.0 0.1 10.7 PI(D21) 50 25 50.0 35.564.5 PII(D42) 50 45 90.0 78.2 96.7 HN4AD PRE 50 1 2.0 0.1 10.7 PI(D21)50 13 26.0 14.6 40.3 PII(D42) 50 42 84.0 70.9 92.8 HN30 = H5N1 30 μgHN15 = H5N1 15 μg HN8 = H5N1 7.5 μg HN4 = H5N1 3.8 μg HN30AD = H5N1 30μg + AS03 HN15AD = H5N1 15 μg + AS03 HN8AD = H5N1 7.5 μg + AS03 HN4AD =H5N1 3.8 μg + AS03 N = number of subjects with available results n/% =number/percentage of subjects with titre within the specified range PRE= Pre-vaccination PI(D21) = Post vaccination at day 21 PII(D42) = Postvaccination at day 42

TABLE 13 Seroconversion rates for anti-HA antibody titer at each post-vaccination at day 21 and day 42 (ATP cohort for immunogenicity)Seroconversion 95% CI Vaccine strain Timing Group N n % LL UL FLUA/VIET/04 AB PI(D21) HN30 49 13 26.5 14.9 41.1 HN15 49 10 20.4 10.2 34.3HN8 49 4 8.2 2.3 19.6 HN4 50 0 0.0 0.0 7.1 HN30AD 48 28 58.3 43.2 72.4HN15AD 49 24 49.0 34.4 63.7 HN8AD 50 25 50.0 35.5 64.5 HN4AD 50 12 24.013.1 38.2 PII(D42) HN30 49 20 40.8 27.0 55.8 HN15 49 17 34.7 21.7 49.6HN8 49 8 16.3 7.3 29.7 HN4 50 2 4.0 0.5 13.7 HN30AD 48 41 85.4 72.2 93.9HN15AD 49 47 95.9 86.0 99.5 HN8AD 50 45 90.0 78.2 96.7 HN4AD 50 41 82.068.6 91.4 HN30 = H5N1 30 μg HN15 = H5N1 15 μg HN8 = H5N1 7.5 μg HN4 =H5N1 3.8 μg HN30AD = H5N1 30 μg + AS03 HN15AD = H5N1 15 μg + AS03 HN8AD= H5N1 7.5 μg + AS03 HN4AD = H5N1 3.8 μg + AS03 N = number of subjectswith available results PI(D21) = Post vaccination at 21 days PII(D42) =Post vaccination at 42 days Data source = Appendix table IIIA n/% =number/percentage of subjects with either a pre-vaccination titer <1:10and post-vaccination titre ≥1:40 or a pre-vaccination titer ≥1:10 and aminimum 4-fold increase in pot-vaccination titer. 95% confidenceinterval, LL = Lower Limit, UL = Upper Limit

In Conclusion:

In case of an influenza pandemic, large proportions of the populationwill be naïve towards the pandemic influenza strain and will likelyrequire 2 doses of vaccine to be protected. To reduce the antigencontent in the potential pandemic vaccine and therefore increase vaccinesupply, adjuvantation strategies are employed after it has been shownthat non-adjuvanted H5N1 candidates vaccines (H5N1 is a leadingcandidate for causing the next influenza pandemic) elicit a immuneresponse only after large doses of antigen (Treanor J J et al. N Engl JMed. 2006; 354:1343-1351).

In this first trial reported herein with a H5N1 pandemic influenzacandidate vaccine with AS03, the following results were obtained:

-   -   There is a clear benefit of the adjuvant AS03 in comparison to        the plain antigen formulations for all different hemagglutinin        doses tested. Post second vaccination, there was a clear        superiority of the adjuvanted groups in GMTs of HI antibody        observed: The GMT of the adjuvanted group receiving the lowest        antigen dose (3.8 μg HA) tested was still 7.5 fold higher than        the highest GMT achieved in the non-adjuvanted groups, elicited        by the highest antigen dose (2 injections a 30 μg of HA). There        was no overlap of 95% CI between either of the adjuvanted groups        with either of the non-adjuvanted groups at day 42.    -   The seroconversion rates at day 42 were 82.0%, 90.0%, 95.9% and        85.6% for the 3.8 μg, 7.5 μg, 15 μg and 30 μg plus adjuvant        groups, respectively. This is for all four antigen contents        adjuvanted with AS03 tested superior to the 40% required by the        European Authorities. Only one of the non adjuvanted groups, the        highest antigen dose group (30 μg), was just able to accomplish        a percentage above the set threshold.    -   At day 42, the seroprotection rates in the four adjuvanted        groups were 84.0%, 90.0%, 95.9% and 85.4% for the 3.8 μg, 7.5        μg, 15 μg and 30 μg plus adjuvant groups, respectively. The        required percentage by the EMEA for the adult age group below 60        years of age is 70%, thereby all adjuvanted groups fulfilled        this criterion, while non of the plain non adjuvanted groups        could achieved the seroprotection rate required.    -   In this study, after two vaccinations with the different        candidate vaccine formulations, the seroconversion factor was        greater than 27.9 (see Table 11, value reached for the HN4AD        group) for the four adjuvanted groups, thereby exceeding largely        the requirement set at 2.5. Also for the non-adjuvanted groups,        the 2 groups receiving the highest antigen doses (15 μg and 30        μg) fulfilled the requirement with 2.8 (HN15 group) and 3.9        (HN30 group).

Regarding the three criteria as set out by the EMEA which are alsoapplicable for the evaluation of pandemic influenza candidate vaccines,all adjuvanted groups achieved after the second dose of the respectiveH5N1 vaccine adjuvanted with AS03 all three criteria defined for thisage group. All adjuvanted groups also achieved the FDA proposed criteriafor seroconversion, seroprotection and conversion factor, after thesecond dose.

IV.7.1.2 Anti-Hemagglutinin Antibody Response Heterologous Strain

Assessing immunogenicity against an antigenically different H5N1 strainfrom the vaccine strain is considered to allow further assess thepotential of a pandemic vaccine candidate. Cross reactivity testing isperformed on the sera of subjects who have received the vaccinationstrain and assesses the potential of the antibodies induced by thevaccine to react to an antigenically different strain. For evaluation ofcross reactivity, H5N1 A/Indonesia/5/2005 was chosen. H5N1 A/Indonesiabelongs to Clade 2, whereas H5N1 A/Vietnam/1194/2004, the vaccinestrain, belongs to Clade 1, and is the first pandemic vaccine prototypestrain from the new genetic group released by WHO. Both strains can betherefore considered antigenically different.

a) Geometric Mean Titres and Seropositivity Against H5N1 Indonesia inStudy H5N1-007 (Table 14)

Seropositive was defined as a HI antibody titer of ≥1:10. All subjectswere seronegative for Indonesia prior to the first vaccination with theVietnam strain. After the second vaccination, up to 48% of subjects ofthe adjuvanted groups (28% 3.8 μg group, 48% 7.5 μg group, 26.5% 15 μggroup, 33.3% 30 μg group) achieved a status of seropositivity. Incomparison, no seropositivity was observed in the 3.8, 7.5 and 15 μgnon-adjuvanted groups at all, while only 2% (1 subject) was found to beseropositive for H5N1 Indonesia in the highest antigen non adjuvantedgroup (30 μg).

TABLE 14 Seropositivity rates and GMTs for HI antibody titer at day 0,day 21 and day 42 by vaccine group (ATP cohort for immunogenicity) ≥=101/DIL GMT 95% CI 95% CI Strain Group Timing N n % LL UL value LL UL MinMax FLU HN30 PRE 49 0 0.0 0.0 7.3 5.0 5.0 5.0 <10.0 <10.0 A/IND/05PI(D21) 49 1 2.0 0.1 10.9 5.1 4.9 5.4 <10.0 20.0 AB PII(D42) 49 1 2.00.1 10.9 5.1 4.9 5.2 <10.0 10.0 HN15 PRE 49 0 0.0 0.0 7.3 5.0 5.0 5.0<10.0 <10.0 PI(D21) 49 0 0.0 0.0 7.3 5.0 5.0 5.0 <10.0 <10.0 PII(D42) 490 0.0 0.0 7.3 5.0 5.0 5.0 <10.0 <10.0 HN8 PRE 49 0 0.0 0.0 7.3 5.0 5.05.0 <10.0 <10.0 PI(D21) 49 0 0.0 0.0 7.3 5.0 5.0 5.0 <10.0 <10.0PII(D42) 49 0 0.0 0.0 7.3 5.0 5.0 5.0 <10.0 <10.0 HN4 PRE 49 0 0.0 0.07.3 5.0 5.0 5.0 <10.0 <10.0 PI(D21) 49 0 0.0 0.0 7.3 5.0 5.0 5.0 <10.0<10.0 PII(D42) 50 0 0.0 0.0 7.1 5.0 5.0 5.0 <10.0 <10.0 HN30AD PRE 48 00.0 0.0 7.4 5.0 5.0 5.0 <10.0 <10.0 PI(D21) 48 4 8.3 2.3 20.0 5.9 4.97.1 <10.0 226.0 PII(D42) 48 16 33.3 20.4 48.4 11.7 8.0 17.2 <10.0 226.0HN15AD PRE 48 0 0.0 0.0 7.4 5.0 5.0 5.0 <10.0 <10.0 PI(D21) 49 2 4.1 0.514.0 5.4 4.8 6.0 <10.0 80.0 PII(D42) 49 13 26.5 14.9 41.1 10.2 7.1 14.7<10.0 226.0 HN8AD PRE 50 0 0.0 0.0 7.1 5.0 5.0 5.0 <10.0 <10.0 PI(D21)50 4 8.0 2.2 19.2 5.7 5.0 6.4 <10.0 40.0 PII(D42) 50 24 48.0 33.7 62.613.9 9.7 20.1 <10.0 320.0 HN4AD PRE 50 0 0.0 0.0 7.1 5.0 5.0 5.0 <10.0<10.0 PI(D21) 50 1 2.0 0.1 10.6 5.1 4.9 5.4 <10.0 20.0 PII(D42) 50 1428.0 16.2 42.5 9.9 7.0 14.0 <10.0 226.0 HN30 = H5N1 30 μg, HN15 = H5N115 μg, HN8 = H5N1 7.5 μg, HN4 = H5N1 3.8 μg HN30AD = H5N1 30 μg + AS03,HN15AD = H5N1 15 μg + AS03, HN8AD = H5N1 7.5 μg + AS03, HN4AD = H5N1 3.8μg + AS03 N = Number of subjects with available results n/% =number/percentage of seropositive subjects (HI titer >= 1:10) 95% CI =95% confidence interval, LL = Lower Limit, UL = Upper Limit GMT =Geometric Mean antibody Titer Min/Max = Minimum/Maximum PRE =Pre-vaccination dose 1 (Day 0) PI(D21) = 21 days after first vaccination(Day 21) PII(D42) = 21 days after second vaccination (Day 42)

b) Seroprotection Against H5N1 Indonesia in Study H5N1-007 (Table 15)

After the second vaccination, despite a much lower sensitivity of HIassay, HI seroprotective titers against the A/Indonesia 5/05 strain weredetectable at day 42, in 20.0% [95% CI: 10.0-33.7] and 32.0% [19.5-46.7]of subjects in the 3.8 μg and 7.5 μg HA adjuvanted vaccine groups butnone of the subjects in the corresponding non-adjuvanted groups. In the15 μg and 30 μg adjuvanted group, 20.4% and 29.2% of subjects had atiter of ≥1:40 after the second vaccination, respectively. None of thesubjects in the non-adjuvanted groups were seroprotected.

TABLE 15 Seroprotection rates (SP) for HI antibody titer at day 0, day21 and day 42 by vaccine group (ATP cohort for immunogenicity) SPVaccine Vaccine 95% CI n % strain Group Timing N n % LL UL UNPROT UNPROTFLU HN30 PRE 49 0 0.0 0.00 7.25 49 100.0 A/IND/05 PI(D21) 49 0 0.0 0.007.25 49 100.0 AB PII(D42) 49 0 0.0 0.00 7.25 49 100.0 HN15 PRE 49 0 0.00.00 7.25 49 100.0 PI(D21) 49 0 0.0 0.00 7.25 49 100.0 PII(D42) 49 0 0.00.00 7.25 49 100.0 HN8 PRE 49 0 0.0 0.00 7.25 49 100.0 PI(D21) 49 0 0.00.00 7.25 49 100.0 PII(D42) 49 0 0.0 0.00 7.25 49 100.0 HN4 PRE 49 0 0.00.00 7.25 49 100.0 PI(D21) 49 0 0.0 0.00 7.25 49 100.0 PII(D42) 50 0 0.00.00 7.11 50 100.0 HN30AD PRE 48 0 0.0 0.00 7.40 48 100.0 PI(D21) 48 24.2 0.51 14.25 46 95.8 PII(D42) 48 14 29.2 16.95 44.06 34 70.8 HN15ADPRE 48 0 0.0 0.00 7.40 48 100.0 PI(D21) 49 1 2.0 0.05 10.85 48 98.0PII(D42) 49 10 20.4 10.24 34.34 39 79.6 HN8AD PRE 50 0 0.0 0.00 7.11 50100.0 PI(D21) 50 1 2.0 0.05 10.65 49 98.0 PII(D42) 50 16 32.0 19.5246.70 34 68.0 HN4AD PRE 50 0 0.0 0.00 7.11 50 100.0 PI(D21) 50 0 0.00.00 7.11 50 100.0 PII(D42) 50 10 20.0 10.03 33.72 40 80.0 HN30 = H5N130 μg, HN15 = H5N1 15 μg, HN8 = H5N1 7.5 μg, HN4 = H5N1 3.8 μg HN30AD =H5N1 30 μg + AS03, HN15AD = H5N1 15 μg + AS03, HN8AD = H5N1 7.5 μg +AS03, HN4AD = H5N1 3.8 μg + AS03 PRE = Pre-vaccination dose 1 (Day 0)PI(D21) = 21 days after first vaccination (Day 21) PII(D42) = 21 daysafter second vaccination (Day 42) N = Number of subjects with availableresults n/% = Number/percentage of seroprotected subjects (HI titer >=1:40) n/% UNPROT = Number/percentage of unprotected subjects (HI titer <1:40) 95% CI = 95% confidence interval, LL = Lower Limit, UL = UpperLimit

c) Seroconversion Against H5N1 Indonesia in Study H5N1-007 (Table 16)

Up to 32.0% of subjects in the adjuvanted groups achieved seroconversionagainst the Indonesia strain not contained in the vaccine. In the 3.8μg, 7.5 μg, 15 μg and 30 μg adjuvanted group, 20.0%, 32.0%, 20.8% and29.2% of subjects seroconverted after the second vaccination,respectively. For none of the subjects in the non-adjuvanted groupsseroconversion could be demonstrated.

TABLE 16 Seroconversion rate (SC) for HI antibody titer at day 21 andday 42 by vaccine group (ATP cohort for immunogenicity) SC VaccineVaccine 95% CI Strain Group Timing N n % LL UL FLU HN30 PI(D21) 49 0 0.00.0 7.3 A/IND/05 PII(D42) 49 0 0.0 0.0 7.3 AB HN15 PI(D21) 49 0 0.0 0.07.3 PII(D42) 49 0 0.0 0.0 7.3 HN8 PI(D21) 49 0 0.0 0.0 7.3 PII(D42) 49 00.0 0.0 7.3 HN4 PI(D21) 48 0 0.0 0.0 7.4 PII(D42) 49 0 0.0 0.0 7.3HN30AD PI(D21) 48 2 4.2 0.5 14.3 PII(D42) 48 14 29.2 17.0 44.1 HN15ADPI(D21) 48 1 2.1 0.1 11.1 PII(D42) 48 10 20.8 10.5 35.0 HN8AD PI(D21) 501 2.0 0.1 10.6 PII(D42) 50 16 32.0 19.5 46.7 HN4AD PI(D21) 50 0 0.0 0.07.1 PII(D42) 50 10 20.0 10.0 33.7 HN30 = H5N1 30 μg, HN15 = H5N1 15 μg,HN8 = H5N1 7.5 μg, HN4 = H5N1 3.8 μg HN30AD = H5N1 30 μg + AS03, HN15AD= H5N1 15 μg + AS03, HN8AD = H5N1 7.5 μg + AS03, HN4AD = H5N1 3.8 μg +AS03 PI(D21) = 21 days after first vaccination (Day 21), PII(D42) = 21days after second vaccination (Day 42) N = number of subjects withavailable results n/% = number/percentage who seroconverted at thespecified POST 95% CI = 95% confidence interval, LL = Lower Limit, UL =Upper Limit

d) Seroconversion Factor Against H5N1 Indonesia in Study H5N1-007

Seroconversion factors between 2 and 2.8 were achieved by the adjuvantedgroups in the trial. In the 3.8 μg, 7.5 μg, 15 μg and 30 μg adjuvantedgroup, the seroconversion factor was 2.0, 2.8, 2.1 and 2.3,respectively.

e) Conclusion on Cross Reactive Data Against H5N1 A/Indonesia

In conclusion, after 2 doses of a split virus candidate vaccineadjuvanted with AS03 adjuvant, cross reactivity data obtained for a H5N1strain from a different clade than the vaccine strain, which has causedconsiderable morbidity and mortality in humans in Asia, were positive.Up to 48% of subjects showed sign of being primed and up to 32% ofsubjects were actually seroprotected against the non vaccine strain.These results show that adjuvantation of a pandemic vaccine can providecross-reactivity against a drift variant of the pandemic strain used inthe vaccine candidate. These results are confirming the potential of theadjuvanted vaccine for priming and cross-priming.

IV. 7.1.3 Neutralizing Antibody Response to Homologous Strain H5N1A/Vietnam

The neutralisation assay is a method which allows for the quantificationof antibodies that inhibit the attachment, the penetration as well asthe propagation of Influenza virus into cells. While for thehaemagglutinin inhibition assay a seroprotection threshold isestablished, this is not the case for this assay. Alternatively, afour-fold increase in neutralizing titre can be used to evaluate whethervaccinated individuals have responded against the vaccination strain ora heterologous strain. Seroconversion rate is one of the keyimmunogenicity parameter used by CHMP/FDA to evaluate effectiveness ofcandidate Influenza vaccines. Testing of serum samples in suchneutralization assay using drift strain would allow predicting, atleast, the frequency of individuals who have been “primed” against agiven strain different from the vaccine strain.

a) Geometric Mean Titres and Seropositivity Measured in NeutralizationAssay Against H5N1 Vietnam in Study H5N1-007 (Table 17)

a)1. Interim Data Obtained on a Limited Number of Subjects Per Groups

The threshold for seropositivity is set at a titre of ≥1:28, theNeutralization assay is also a highly sensitive test. GMT's at day 0ranged from 14.0 to 18.1 in the non adjuvanted and from 18.5 to 25.2 inthe adjuvanted groups. After the second vaccination, titres increasedfor the non adjuvanted groups as a dose dependent manner to 43.9, 61.7,86.9 and 177.8 for the 3.8, 7.5, 15 and 30 μg groups respectively. Inthe adjuvanted groups, titres of 381.0, 421.2, 464.7 and 333.3 for the3.8, 7.5, 15 and 30 μg groups respectively were achieved, exactlyrepeating the observation made in HI titers: from 3.8 μg over 7.5 μg tothe 15 μg adjuvanted group a dose dependant increase in GMT was observed(Table 17A and FIG. 10A1).

TABLE 17A Seropositivity rates and GMTs for Neutralizing antibody titerat day 0, day 21 and day 42 (ATP cohort for immunogenicity) >=28 1/DILGMT 95% CI 95% CI Strain Group Timing N n % LL UL value LL UL Min MaxFLU A/ HN30 PRE 25 4 16.0 4.5 36.1 18.2 14.0 23.6 <28.0 113.0 VIET/04 ABPI(D21) 25 23 92.0 74.0 99.0 114.1 76.3 170.7 <28.0 905.0 PII(D42) 25 25100 86.3 100 177.8 120.5 262.2 28.0 905.0 HN15 PRE 43 15 34.9 21.0 50.923.0 18.1 29.4 <28.0 226.0 PI(D21) 43 34 79.1 64.0 90.0 70.0 48.5 101.0<28.0 905.0 PII(D42) 43 38 88.4 74.9 96.1 86.9 63.6 118.9 <28.0 720.0HN8 PRE 40 13 32.5 18.6 49.1 21.8 17.4 27.3 <28.0 113.0 PI(D21) 40 2972.5 56.1 85.4 44.7 33.7 59.4 <28.0 226.0 PII(D42) 40 34 85.0 70.2 94.361.7 47.5 80.1 <28.0 284.0 HN4 PRE 43 13 30.2 17.2 46.1 20.8 16.9 25.5<28.0 113.0 PI(D21) 43 30 69.8 53.9 82.8 40.0 30.8 52.0 <28.0 226.0PII(D42) 43 33 76.7 61.4 88.2 43.9 34.4 55.9 <28.0 284.0 HN30AD PRE 25 624.0 9.4 45.1 18.5 14.9 23.1 <28.0 57.0 PI(D21) 25 24 96.0 79.6 99.9200.3 137.3 292.2 <28.0 905.0 PII(D42) 25 25 100 86.3 100 333.3 246.7450.4 57.0 1420.0 HN15AD PRE 43 14 32.6 19.1 48.5 22.3 17.8 28.0 <28.0180.0 PI(D21) 43 43 100 91.8 100 203.1 161.4 255.6 57.0 905.0 PII(D42)43 43 100 91.8 100 464.7 372.7 579.4 113.0 2260.0 HN8AD PRE 42 16 38.123.6 54.4 25.2 19.2 33.1 <28.0 284.0 PI(D21) 42 41 97.6 87.4 99.9 160.7121.5 212.6 <28.0 1420.0 PII(D42) 42 41 97.6 87.4 99.9 421.2 319.4 555.4<28.0 1440.0 HN4AD PRE 44 16 36.4 22.4 52.2 23.0 18.5 28.6 <28.0 113.0PI(D21) 44 43 97.7 88.0 99.9 135.9 109.4 168.9 <28.0 905.0 PII(D42) 4343 100 91.8 100 381.0 306.0 474.4 57.0 1420.0 HN30 = H5N1 30 μg; HN15 =H5N1 15 μg; HN8 = H5N1 7.5 μg; HN4 = H5N1 3.8 μg HN30AD = H5N1 30 μg +AS03; HN15AD = H5N1 15 μg + AS03; HN8AD = H5N1 7.5 μg + AS03; HN4AD =H5N1 3.8 μg + AS03 N = Number of subjects with available results n/% =number/percentage of seropositive subjects (HI titer >= 1:10) 95% CI =95% confidence interval, LL = Lower Limit, UL = Upper Limit GMT =Geometric Mean antibody Titer Min/Max = Minimum/Maximum PRE =Pre-vaccination dose 1 (Day 0) PI(D21) = 21 days after first vaccination(Day 21) PII(D42) = 21 days after second vaccination (Day 42)

a)2. Data Obtained on the Total Cohort

The threshold for seropositivity is set at a titre of 1:28, theNeutralization assay is also a highly sensitive test. GMT's at day 0ranged from 18.9 to 22.6 in the non adjuvanted and from 17.3 to 23.3 inthe adjuvanted groups. After the second vaccination, titres increasedfor the non adjuvanted groups as a dose dependent manner to 40.7, 53.4,80.1 and 113.6 for the 3.8, 7.5, 15 and 30 μg groups respectively. Inthe adjuvanted groups, titres of 314.7, 343.0, 400.1 and 258.2 for the3.8, 7.5, 15 and 30 μg groups respectively were achieved, exactlyrepeating the observation made in HI titers: from 3.8 μg over 7.5 μg tothe 15 μg adjuvanted group a dose dependant increase in GMT was observed(Table 17B and FIG. 10A2).

TABLE 17B Seropositivity rates and GMTs (with 95% CI) for theneutralizing antibodies against the vaccine strain (Vietnam strain) atDay 0, Day 21 and Day 42 (ATP cohort for Immunogenicity) ≥28 1/DIL GMT95% CI 95% CI Antibody Group Timing N n % LL UL value LL UL Min Max FLUHN30 PRE 49 12 24.5 13.3 38.9 18.9 16.0 22.3 <28.0 113.0 A/VIET/04PI(D21) 49 44 89.8 77.8 96.6 80.1 61.0 105.3 <28.0 905.0 AB PII(D42) 4846 95.8 85.7 99.5 113.6 85.5 150.9 <28.0 905.0 HN15 PRE 49 17 34.7 21.749.6 22.6 18.2 28.2 <28.0 226.0 PI(D21) 48 38 79.2 65.0 89.5 66.9 47.993.4 <28.0 905.0 PII(D42) 49 43 87.8 75.2 95.4 80.1 60.1 107.0 <28.0720.0 HN8 PRE 49 15 30.6 18.3 45.4 20.9 17.2 25.2 <28.0 113.0 PI(D21) 4933 67.3 52.5 80.1 40.3 31.2 52.1 <28.0 226.0 PII(D42) 49 38 77.6 63.488.2 53.4 41.6 68.6 <28.0 284.0 HN4 PRE 50 14 28.0 16.2 42.5 20.2 16.824.3 <28.0 113.0 PI(D21) 50 31 62.0 47.2 75.3 35.5 27.8 45.4 <28.0 226.0PII(D42) 50 36 72.0 57.5 83.8 40.7 32.4 51.0 <28.0 284.0 HN30AD PRE 48 918.8 8.9 32.6 17.3 15.1 20.0 <28.0 90.0 PI(D21) 47 45 95.7 85.5 99.5146.6 113.3 189.8 <28.0 905.0 PII(D42) 47 47 100 92.5 100 258.2 205.5324.5 28.0 1420.0 HN15AD PRE 49 16 32.7 19.9 47.5 22.0 17.9 27.0 <28.0180.0 PI(D21) 49 49 100 92.7 100 181.3 144.6 227.3 45.0 905.0 PII(D42)49 49 100 92.7 100 400.1 319.3 501.4 113.0 2260.0 HN8AD PRE 50 17 34.021.2 48.8 23.3 18.4 29.4 <28.0 284.0 PI(D21) 49 47 95.9 86.0 99.5 134.6101.3 178.7 <28.0 1420.0 PII(D42) 50 49 98.0 89.4 99.9 343.0 260.5 451.5<28.0 1440.0 HN4AD PRE 50 16 32.0 19.5 46.7 21.7 17.8 26.4 <28.0 113.0PI(D21) 50 48 96.0 86.3 99.5 117.9 93.7 148.3 <28.0 905.0 PII(D42) 49 4898.0 89.1 99.9 314.7 243.1 407.3 <28.0 1420.0 HN30 = H5N1 30 μg HN15 =H5N1 15 μg HN8 = H5N1 7.5 μg HN4 = H5N1 3.8 μg HN30AD = H5N1 30 μg +AS03 HN15AD = H5N1 15 μg + AS03 HN8AD = H5N1 7.5 μg + AS03 HN4AD = H5N13.8 μg + AS03 N = Number of subjects with available results n/% =number/percentage of seropositive subjects (SN titer >= 1:28) 95% CI =95% confidence interval, LL = Lower Limit, UL = Upper Limit GMT =Geometric Mean antibody Titer Min/Max = Minimum/Maximum PRE =Pre-vaccination dose 1 (Day 0) PI(D21) = 21 days after first vaccination(Day 21) PII(D42) = 21 days after second vaccination (Day 42)

b) Seroconversion Rates for Neutralizing Antibody Titers Against H5N1Vietnam in Study H5N1-007 (Table 18)

As mentioned above, a four fold increase is used to determineseroconversion against an influenza strain. Therefore, subjectsseropositive at day 0 are only included if they achieved a fourfoldincrease, thereby subtracting a potential background.

b)1. Interim Data Obtained on a Limited Number of Subjects Per Groups

After the second dose, seroconversion in the non adjuvanted groups againcould be observed in a dose dependent manner: 20.9, 37.5, 53.5 and 76.0%of subjects seroconverted in the 3.8, 7.5, 15 and 30 μg groupsrespectively. In the adjuvanted groups, 86.0, 83.3, 86.0 and 100.0% ofsubjects in the 3.8, 7.5, 15 and 30 μg groups respectivelyseroconverted, thereby also confirming the HI results. Of note, afterthe first dose of adjuvanted vaccine, already 66.7 to 88.0% of subjectshad seroconverted in the four adjuvanted groups (Table 18A and FIG.10B1).

TABLE 18A Seroconversion rates (SC) for Neutralizing antibody titer(from Dresden) at each post-vaccination time point (ATP cohort forimmunogenicity) SC 95% CI Strain Timing Group N n % LL UL FLU A/ day 21HN30 25 19 76.0 54.9 90.6 VIET/04 AB HN15 43 20 46.5 31.2 62.3 HN8 40 922.5 10.8 38.5 HN4 43 7 16.3 6.8 30.7 HN30AD 25 22 88.0 68.8 97.5 HN15AD43 37 86.0 72.1 94.7 HN8AD 42 28 66.7 50.5 80.4 HN4AD 44 30 68.2 52.481.4 day 42 HN30 25 19 76.0 54.9 90.6 HN15 43 23 53.5 37.7 68.8 HN8 4015 37.5 22.7 54.2 HN4 43 9 20.9 10.0 36.0 HN30AD 25 25 100.0 86.3 100.0HN15AD 43 37 86.0 72.1 94.7 HN8AD 42 35 83.3 68.6 93.0 HN4AD 43 37 86.072.1 94.7 HN30 = H5N1 30 μg; HN15 = H5N1 15 μg; HN8 = H5N1 7.5 μg; HN4 =H5N1 3.8 μg HN30AD = H5N1 30 μg + AS03; HN15AD = H5N1 15 μg + AS03;HN8AD = H5N1 7.5 μg + AS03; HN4AD = H5N1 3.8 μg + AS03 N = Number ofsubjects with available results n/% = Number/percentage of subjects whoseroconverted (at least a 4-fold increase at POST) 95% CI = 95%confidence interval, LL = Lower Limit, UL = Upper Limit

b)2. Data Obtained on the Total Cohort

After the second dose, seroconversion in the non adjuvanted groups againcould be observed in a dose dependent manner: 22.0, 36.7, 53.1 and64.6.0% of subjects seroconverted in the 3.8, 7.5, 15 and 30 μg groupsrespectively. In the adjuvanted groups, 85.7, 86.0, 85.7 and 97.9% ofsubjects in the 3.8, 7.5, 15 and 30 μg groups respectivelyseroconverted, thereby also confirming the HI results. Of note, afterthe first dose of adjuvanted vaccine, already 66.0 to 83.7% of subjectshad seroconverted in the four adjuvanted groups (Table 18B and FIG.10B2).

TABLE 18B Seroconversion rates (SC with 95% CI) for the neutralizingantibodies against the vaccine strain (Vietnam strain) at eachpost-vaccination time point (ATP cohort for Immunogenicity) SC with 95%CI Vaccine strain Timing Group N n % LL UL FLU A/VIET/04 AB PI(D21) HN3049 28 57.1 42.2 71.2 HN15 48 23 47.9 33.3 62.8 HN8 49 11 22.4 11.8 36.6HN4 50 7 14.0 5.8 26.7 HN30AD 47 39 83.0 69.2 92.4 HN15AD 49 41 83.770.3 92.7 HN8AD 49 31 63.3 48.3 76.6 HN4AD 50 33 66.0 51.2 78.8 PII(D42)HN30 48 31 64.6 49.5 77.8 HN15 49 26 53.1 38.3 67.5 HN8 49 18 36.7 23.451.7 HN4 50 11 22.0 11.5 36.0 HN30AD 47 46 97.9 88.7 99.9 HN15AD 49 4285.7 72.8 94.1 HN8AD 50 43 86.0 73.3 94.2 HN4AD 49 42 85.7 72.8 94.1HN30 = H5N1 30 μg HN15 = H5N1 15 μg HN8 = H5N1 7.5 μg HN4 = H5N1 3.8 μgHN30AD = H5N1 30 μg + AS03 HN15AD = H5N1 15 μg + AS03 HN8AD = H5N1 7.5μg + AS03 HN4AD = H5N1 3.8 μg + AS03 N = Number of subjects withavailable results (ATP cohort for immunogenicity) n/% =Number/percentage of subjects who seroconverted (at least a 4-foldincrease at POST) 95% CI = 95% confidence interval, LL = Lower Limit, UL= Upper Limit

The GMT titers and seroconversion rates for the Vietnam strain areillustrated in 18A and 18B respectively. Adjuvantation markedly improvedin vitro neutralising antibody responses in the adjuvanted groupscompared to the non-adjuvanted groups with 5 to 8 fold differencesobserved after the second dose for the three lower antigen levels. Theadjuvant effect was also evident in the neutralising seroconversionrates and was most marked at the lower antigen levels after the seconddose. In conclusion, neutralizing antibodies measured against thevaccine strain (Vietnam), support the results obtained by the HI. Alladjuvanted groups including the lowest dose group of 3.8 μg achieved aseroconversion in over 65% after the first and over 80% of subjects(partial data) and over 85% of subjects (total data) tested after thesecond dose of the pandemic candidate vaccine. It is worth noting thatpost first dose, neutralization seroconversion rates were higher thanthose for HAI. The haemagglutination-inhibition results indicate theproduction of antibodies that specifically block the haemagglutininreceptor-binding site involved in attachment of the virus to the hostcell. The neutralising results however confirm the production ofbiologically functional antibodies that can inhibit the complex processof virus attachment, entry and release from cells in tissue culture.

IV.7.1.4 Neutralizing Antibody Response to Heterologous Strain H5N1A/Indonesia

As already discussed, due to the nature of the neutralization assaymeasuring antibodies that inhibit the penetration into the cell andpropagation from cell to cell of the influenza virus in addition to theinhibition of the attachment of the virus, evaluating the drift strainallows to further assess the potential of the vaccine to prime also fora non-vaccine strain.

a) Geometric Mean Titres and Seropositivity Measured in NeutralizationAssay Against H5N1 A/Indonesia in Study H5N1-007 (Table 19)

a)1. Partial Data with 3.8 μg and 7.5 μg HA Adjuvanted Groups Only

Partial data (of the 3.8 μg and 7.5 μg HA adjuvanted groups only) arepresented herein below. In these two lowest adjuvanted groups, GMTsagainst the Indonesia strain achieved after two doses of the vaccinewere 70.6 and 73.1 for the 3.8 μg and 7.5 μg adjuvanted group,respectively (Table 19A).

TABLE 19A Seropositivity rates and GMTs of Neutralizing antibody titerfor Indonesia strain at day 0, day 21 and day 42 (ATP cohort forimmunogenicity) >=28 1/DIL GMT 95% CI 95% CI Antibody Group Timing N n %LL UL value LL UL Min Max FLU A/IND/05 HN8AD PRE 35 8 22.9 10.4 40.117.6 15.1 20.4 <28.0 57.0 AB PI(D21) 35 27 77.1 59.9 89.6 47.5 35.3 64.0<28.0 284.0 PII(D42) 35 34 97.1 85.1 99.9 99.0 73.1 134.0 <28.0 453.0HN4AD PRE 38 4 10.5 2.9 24.8 16.3 13.9 19.1 <28.0 113.0 PI(D21) 38 2873.7 56.9 86.6 41.9 31.9 55.1 <28.0 226.0 PII(D42) 38 34 89.5 75.2 97.193.1 70.6 122.7 <28.0 284.0 HN8AD = H5N1 7.5 μg + AS03, HN4AD = H5N1 3.8μg + AS03 N = Number of subjects with available results n/% =number/percentage of seropositive subjects (HI titer >= 1:10) 95% CI =95% confidence interval, LL = Lower Limit, UL = Upper Limit GMT =Geometric Mean antibody Titer Min/Max = Minimum/Maximum PRE =Pre-vaccination dose 1 (Day 0), PI(D21) = 21 days after firstvaccination (Day 21), PII(D42) = 21 days after second vaccination (Day42)a)2. Total Data with all Groups

In the adjuvanted groups, GMTs against the Indonesia strain achievedafter two doses of the vaccine were 80.3, 95.7, 72.9 and 66.8 for the3.8, 7.5, 15 and 30 μg adjuvanted groups respectively. GMTs in the nonadjuvanted groups were lower with 14.5, 15.0, 16.5 and 20.6 in the 3.8,7.5, 15 and 30 μg groups respectively (Table 19B and FIG. 10C).

TABLE 19B Seropositivity rates and GMTs (with 95% CI) for theneutralizing antibodies against the Indonesia strain at Day 0, Day 21and Day 42 (ATP cohort for Immunogenicity) >28 1/DIL GMT 95% CI 95% CIAntibody Group Timing N n % LL UL value LL UL Min Max FLU HN30 PRE 49 24.1 0.5 14.0 14.5 13.8 15.2 <28.0 36.0 A/IND/05 PI(D21) 48 20 41.7 27.656.8 24.9 20.0 30.8 <28.0 142.0 AB PII(D42) 48 15 31.3 18.7 46.3 20.617.2 24.6 <28.0 113.0 HN15 PRE 45 0 0.0 0.0 7.9 14.0 14.0 14.0 <28.0<28.0 PI(D21) 43 6 14.0 5.3 27.9 16.9 14.2 20.2 <28.0 226.0 PII(D42) 447 15.9 6.6 30.1 16.5 14.6 18.7 <28.0 90.0 HN8 PRE 44 1 2.3 0.1 12.0 14.213.8 14.7 <28.0 28.0 PI(D21) 43 5 11.6 3.9 25.1 15.4 14.2 16.8 <28.045.0 PII(D42) 44 3 6.8 1.4 18.7 15.0 13.8 16.3 <28.0 45.0 HN4 PRE 43 00.0 0.0 8.2 14.0 14.0 14.0 <28.0 <28.0 PI(D21) 43 1 2.3 0.1 12.3 14.513.5 15.4 <28.0 57.0 PII(D42) 43 1 2.3 0.1 12.3 14.5 13.5 15.7 <28.071.0 HN30AD PRE 47 0 0.0 0.0 7.5 14.0 14.0 14.0 <28.0 <28.0 PI(D21) 4638 82.6 68.6 92.2 54.6 42.5 70.1 <28.0 284.0 PII(D42) 46 42 91.3 79.297.6 66.8 53.4 83.5 <28.0 226.0 HN15AD PRE 44 1 2.3 0.1 12.0 14.2 13.814.7 <28.0 28.0 PI(D21) 44 35 79.5 64.7 90.2 38.1 30.0 48.5 <28.0 287.0PII(D42) 44 41 93.2 81.3 98.6 72.9 58.5 90.9 <28.0 226.0 HN8AD PRE 47 1021.3 10.7 35.7 17.3 15.2 19.5 <28.0 57.0 PI(D21) 47 34 72.3 57.4 84.443.7 33.7 56.6 <28.0 284.0 PII(D42) 46 45 97.8 88.5 99.9 95.7 75.3 121.7<28.0 453.0 HN4AD PRE 48 4 8.3 2.3 20.0 15.8 13.9 17.9 <28.0 113.0PI(D21) 48 32 66.7 51.6 79.6 36.6 28.8 46.5 <28.0 226.0 PII(D42) 48 4287.5 74.8 95.3 80.3 62.0 103.9 <28.0 284.0 HN30 = H5N1 30 μg HN15 = H5N115 μg HN8 = H5N1 7.5 μg HN4 = H5N1 3.8 μg HN30AD = H5N1 30 μg + AS03HN15AD = H5N1 15 μg + AS03 HN8AD = H5N1 7.5 μg + AS03 HN4AD = H5N1 3.8μg + AS03 N = Number of subjects with available results n/% =number/percentage of seropositive subjects (SN titer >= 1:28) 95% CI =95% confidence interval, LL = Lower Limit, UL = Upper Limit GMT =Geometric Mean antibody Titer Min/Max = Minimum/Maximum PRE =Pre-vaccination dose 1 (Day 0) PI(D21) = 21 days after first vaccination(Day 21)

b) Seroconversion Rates for Neutralizing Antibody Titers Against H5N1A/Indonesia in Study H5N1-007 (Table 20)

b)1. Partial Data with 3.8 μg and 7.5 μg HA Adjuvanted Groups Only Boththe 3.8 and 7.5 μg adjuvanted groups received a high seroconversion rateagainst the antigenically different non-vaccination strain: 84.2% ofsubjects seroconverted when tested against the A/Indonesia strain (Table20A).

TABLE 20A Seroconversion rates (SC) of Neutralizing antibody titer forIndonesia strain at each post-vaccination time point (ATP cohort forimmunogenicity) SC (4 fold) Vaccine 95% CI Strain Timing Group N n % LLUL FLU A/IND/05 PI(D21) HN8AD 35 13 37.1 21.5 55.1 AB HN4AD 38 15 39.524.0 56.6 PII(D42) HN8AD 35 22 62.9 44.9 78.5 HN4AD 38 32 84.2 68.7 94.0HN8AD = H5N1 7.5 μg + AS03, HN4AD = H5N1 3.8 μg + AS03 PRE =Pre-vaccination dose 1 (Day 0), PI(D21) = 21 days after firstvaccination (Day 21), PII(D42) = 21 days after second vaccination (Day42) N = Number of subjects with available results n/% =Number/percentage of subjects who seroconverted (at least a 4-foldincrease at POST) 95% CI = 95% confidence interval, LL = Lower Limit, UL= Upper Limit

These preliminary available data on the cross-reactivity in theneutralization assay indicate a remarkable effect of the adjuvantedvaccine containing a heterologous strain to the tested Indonesia strainand confirm the cross-reactive potential of the candidate vaccine.

b)2. Total Data with all Groups

Using neutralization assay to measure cross-reactive immunologicalresponse, results showed very high seroconversion rates at day 42, of77.1% [62.7-88.0] and 67.4% [52.0-80.5] against the antigenicallydifferent Indonesia strain in the 3.8 μg and 7.5 μg HA adjuvantedvaccine group, respectively (see Table 20B). In the correspondingnon-adjuvanted vaccine groups the seroconversion rates were <3%. Ofnote, seroconversion rates after the first does ranked for theadjuvanted groups between 27.3 and 54.3% against the Indonesianon-vaccine strain (Table 20B and FIG. 10D).

TABLE 20B Seroconversion rates (SC with 95% CI) for the neutralizingantibodies against Indonesia strain at each post-vaccination time point(ATP cohort for immunogenicity) Vaccine SC with 95% CI Strain TimingGroup N n % LL UL FLU A/IND/05 AB PI(D21) HN30 48 9 18.8 8.9 32.6 HN1543 2 4.7 0.6 15.8 HN8 43 0 0.0 0.0 8.2 HN4 43 1 2.3 0.1 12.3 HN30AD 4625 54.3 39.0 69.1 HN15AD 44 12 27.3 15.0 42.8 HN8AD 47 17 36.2 22.7 51.5HN4AD 48 15 31.3 18.7 46.3 PII(D42) HN30 48 4 8.3 2.3 20.0 HN15 44 1 2.30.1 12.0 HN8 44 0 0.0 0.0 8.0 HN4 43 1 2.3 0.1 12.3 HN30AD 46 29 63.047.5 76.8 HN15AD 44 30 68.2 52.4 81.4 HN8AD 46 31 67.4 52.0 80.5 HN4AD48 37 77.1 62.7 88.0 HN30 = H5N1 30 μg HN15 = H5N1 15 μg HN8 = H5N1 7.5μg HN4 = H5N1 3.8 μg HN30AD = H5N1 30 μg + AS03 HN15AD = H5N1 15 μg +AS03 HN8AD = H5N1 7.5 μg + AS03 HN4AD = H5N1 3.8 μg + AS03 PRE =Pre-vaccination dose 1 (Day 0) PI(D21) = 21 days after first vaccination(Day 21) PI I(D42) = 21 days after second vaccination (Day 42) N =Number of subjects with available results n/% = Number/percentage ofsubjects who seroconverted (at least a 4-fold increase at POST) 95% CI =95% confidence interval, LL = Lower Limit, UL = Upper Limit Data source= Appendix table IIIA

The data on the cross-reactivity in the neutralization assay indicate aremarkable effect of the adjuvanted vaccine containing a heterologousstrain to the tested Indonesia strain and confirm the cross-reactivepotential of the candidate vaccine at the lowest dose of 3.8 μg. Thecross-clade neutralizing antibody responses observed infer that theAS03-adjuvanted vaccine could be deployed for a pre-pandemicimmunisation.

IV.7.1.5 Cell Mediated Immunity (CMI)

For evaluation of CMI, please see sections 1.2, 1.3, and IV.3.2. One ofthe important features of an adjuvant in enhancing the immunogenicity ofa vaccine is the ability to stimulate the cell mediated immunity, CMI.In this trial, an assessment of influenza specific CD4- and CD8-cellsincluding frequencies of Th1 related cytokines as well as the evaluationof frequency of Memory B-cells was foreseen. Data are available for theT-cell responses of the two lowest antigen groups, adjuvanted or notwith AS03.

CMI results are expressed as a frequency of cytokine(s)-positive CD4 Tcells.

Median values (including first and third quartiles, see Table 21) arepresented in FIG. 11. The results indicated that the adjuvanted groupsclearly induced a much stronger CD4 response in comparison to thenon-adjuvanted groups.

TABLE 21 Descriptive Statistics on the frequency-positive CD4 T-cells(per million CD4 T-cells) at each time point (ATP cohort forimmunogenicity) Test Vaccine N Strain Description Group Timing N miss.GMT Q1 Median Q3 Max H5N1 CD4- HN4 Day 0 49 1 689.35 463.00 697.001120.00 2888.00 Vietnam ALL Day 21 48 2 1358.91 912.50 1432.50 1949.006690.00 DOUBLES Day 42 49 1 1522.31 1076.00 1647.00 2163.00 4809.00HN4AD Day 0 49 1 801.27 620.00 878.00 1074.00 2217.00 Day 21 49 12667.58 2206.00 3051.00 4568.00 10945.00 Day 42 49 1 3093.61 2337.003046.00 4008.00 8879.00 HN8 Day 0 48 1 664.71 601.00 834.50 1257.502913.00 Day 21 46 3 1403.87 1078.00 1535.00 2017.00 2757.00 Day 42 49 01238.36 1062.00 1575.00 1906.00 2910.00 HN8AD Day 0 47 3 627.79 525.00782.00 1093.00 3215.00 Day 21 49 1 3027.63 2304.00 3495.00 5178.0011376.00 Day 42 48 2 3397.59 2511.00 3323.00 4923.00 9134.00 CD4- HN4Day 0 49 1 674.26 460.00 680.00 1120.00 2847.00 CD4OL Day 21 48 21315.89 867.00 1365.00 1926.50 6691.00 Day 42 49 1 1481.49 1076.001582.00 2075.00 4684.00 HN4AD Day 0 49 1 771.85 594.00 815.00 1048.002102.00 Day 21 49 1 2576.31 2114.00 3010.00 4504.00 10503.00 Day 42 49 13005.85 2247.00 2940.00 3782.00 8535.00 HN8 Day 0 48 1 656.81 530.00799.00 1142.00 2813.00 Day 21 46 3 1362.22 1053.00 1531.50 1876.002757.00 Day 42 49 0 1189.79 1032.00 1466.00 1906.00 2792.00 HN8AD Day 047 3 615.32 512.00 775.00 1021.00 2951.00 Day 21 49 1 3001.77 2189.003371.00 4762.00 11124.00 Day 42 48 2 3295.38 2388.00 3167.50 4804.508690.00 CD4- HN4 Day 0 49 1 409.56 237.00 420.00 727.00 2560.00 IFNG Day21 48 2 719.52 440.00 806.00 1097.50 3618.00 Day 42 49 1 758.46 563.00715.00 1045.00 2402.00 HN4AD Day 0 49 1 476.45 333.00 584.00 778.001903.00 Day 21 49 1 1003.77 849.00 1240.00 1986.00 5743.00 Day 42 49 11321.30 929.00 1328.00 1672.00 3945.00 HN8 Day 0 48 1 462.73 322.00509.50 979.50 2423.00 Day 21 46 3 694.95 580.00 849.50 1254.00 2104.00Day 42 49 0 714.16 531.00 876.00 1079.00 2146.00 HN8AD Day 0 47 3 398.24241.00 490.00 637.00 2531.00 Day 21 49 1 1406.88 980.00 1465.00 2587.006676.00 Day 42 48 2 1471.29 967.00 1417.50 2444.00 4763.00 CD4- HN4 Day0 49 1 595.36 384.00 613.00 1049.00 2145.00 IL2 Day 21 48 2 1223.32787.00 1276.00 1804.00 6000.00 Day 42 49 1 1370.12 1027.00 1479.002016.00 4233.00 HN4AD Day 0 49 1 686.60 501.00 770.00 965.00 1795.00 Day21 49 1 2479.78 2082.00 2963.00 4348.00 10102.00 Day 42 49 1 2797.792062.00 2758.00 3617.00 8095.00 HN8 Day 0 48 1 611.24 515.50 744.001093.50 2638.00 Day 21 46 3 1225.92 1003.00 1374.00 1742.00 2606.00 Day42 49 0 1099.43 942.00 1374.00 1706.00 2536.00 HN8AD Day 0 47 3 484.64458.00 665.00 982.00 2588.00 Day 21 49 1 2591.08 2015.00 3205.00 4678.0010746.00 Day 42 48 2 3056.63 2172.00 2981.50 4462.00 8662.00 CD4- HN4Day 0 49 1 566.24 353.00 590.00 957.00 2270.00 TNFA Day 21 48 2 995.66655.00 1089.00 1523.00 5373.00 Day 42 49 1 1039.47 733.00 1240.001532.00 3492.00 HN4AD Day 0 49 1 595.65 538.00 691.00 867.00 1760.00 Day21 49 1 1703.32 1471.00 1859.00 3174.00 7577.00 Day 42 49 1 2286.391711.00 2222.00 2957.00 7650.00 HN8 Day 0 48 1 526.47 435.50 643.001036.50 2489.00 Day 21 46 3 1004.27 708.00 1120.50 1516.00 1976.00 Day42 49 0 856.00 740.00 994.00 1363.00 2396.00 HN8AD Day 0 47 3 504.74401.00 628.00 908.00 2892.00 Day 21 49 1 2099.73 1486.00 2373.00 3822.006886.00 Day 42 48 2 2442.38 1786.50 2400.50 3564.50 7629.00 HN8 = H5N17.5 μg HN4 = H5N1 3.8 μg HN8AD = H5N1 7.5 μg + AS03 HN4AD = H5N1 3.8μg + AS03 N = number of subjects with available results; N miss. =number of subjects with missing results GM = Geometric Mean SD =Standard Deviation Q1, Q3 = First and third quartiles MIN/MAX =Minimum/Maximum

In the inferential analysis it was confirmed that both after the firstvaccination at day 21 (with exception of IFN gamma positive CD4 cells)and after the second vaccination at day 42, the induction of cytokinepositive CD 4 cells was significantly higher in the adjuvanted group incomparison to the non-adjuvanted group receiving the same dose.Therefore, the adjuvant effect seen in the serological evaluation of theantibodies induced by the vaccine was confirmed by the CMI results. In asimilar fashion the analysis shows that the effect on CMI is clearlyadjuvant-, but not dose-dependant (comparison of the 3.8 μg and the 7.5μg doses only), which is consistent with the HI results (see Table 22).

TABLE 22 Inferential statistics (p-values from Kruskal-Wallis Tests) onthe frequency cytokine-positive CD4 T-cells at each time point P_valueat P_value at P_value at Groups compared Test Description Day 0 Day 21Day 42 Adjuvant effect HN4 and HN4AD CD4-ALL 0.2150 <0.0001 <0.0001DOUBLES CD4-CD4OL 0.2190 <0.0001 <0.0001 CD4-IFNG 0.1320 0.0012 <0.0001CD4-IL2 0.2497 <0.0001 <0.0001 CD4-TNFA 0.3130 <0.0001 <0.0001 HN8 andHN8AD CD4-ALL 0.4433 <0.0001 <0.0001 DOUBLES CD4-CD4OL 0.4749 <0.0001<0.0001 CD4-IFNG 0.2771 <0.0001 <0.0001 CD4-IL2 0.3114 <0.0001 <0.0001CD4-TNFA 0.4657 <0.0001 <0.0001 Dose effect HN4 and HN8 CD4-ALL 0.26030.6774 0.3880 DOUBLES CD4-CD4OL 0.2872 0.6941 0.3181 CD4-IFNG 0.20540.3641 0.6366 CD4-IL2 0.2338 0.8264 0.2677 CD4-TNFA 0.3538 0.9067 0.2137HN4AD and CD4-ALL 0.4055 0.3958 0.2146 HN8AD DOUBLES CD4-CD4OL 0.40760.4366 0.2424 CD4-IFNG 0.1498 0.1037 0.2146 CD4-IL2 0.3242 0.5673 0.2528CD4-TNFA 0.4703 0.3268 0.3787 HN8 = H5N1 7.5 μg HN4 = H5N1 3.8 μg HN8AD= H5N1 7.5 μg + AS03 HN4AD = H5N1 3.8 μg + AS03

In addition, the CMI response against pools of peptides covering H5 ofA/Vietnam/1194/2004 and A/Indonesia/5/2005 was tested in the 3.8 μg and7.5 μg adjuvanted and non-adjuvanted groups:

-   -   pool “Viet Total”: covering the entire AA sequence of H5        (A/Vietnam/1194/2004)    -   pool “Viet-Indo Cons”: covering all AA parts of sequences of H5        conserved between the 2 strains: A/Vietnam/1194/2004 and        A/Indonesia/5/05    -   pool “Viet NC”: covering all AA parts of sequences of H5 not        conserved of A/Vietnam/1194/2004 (comparing with        A/Indonesia/5/05)    -   pool “Indo NC”: covering all AA part of sequences of H5 not        conserved of A/Indonesia/5/05 (comparing with        A/Vietnam/1194/2004)

Antigen specific CD4 and CD 8 T-cell responses are again expressed in 5different tests:

-   -   CD40L: cells producing at least CD40L and another cytokine        (IFNγ, IL-2, TNFα)    -   IL-2: cells producing at least IL-2 and another cytokine (CD40L,        TNFα, IFNγ)    -   TNFα: cells producing at least TNFα and another cytokine (CD40L,        IL-2, IFNγ)    -   IFNγ: cells producing at least IFNγ and another cytokine (IL-2,        TNFα, CD40L)    -   all doubles: cells producing at least two different cytokines        (CD40L, IL-2, TNFα, IFNγ)

In summary, regarding the CD 4 T-cell response specific to H5 proteins,the H5-specific CD4 response was significantly higher in adjuvanted (7.5μg and 3.8 μg) groups compared to non-adjuvanted groups. The H5-specificCD4 T cells express mainly CD40 ligand and IL-2, to a lower extend TNFαand a very low level of IFNγ. As expected was the specific response toH5 proteins (i.e., to the peptide pools used) lower than the response toH5N1 split antigen. The cross reactivity evaluation of the CMI responseto H5 Indonesia protein showed the following results:

-   -   a significant proportion (around 70%) of the H5 Vietnam-specific        CD4 T-cell response recognized the conserved sequence between H5        Indonesia and H5 Vietnam,    -   also a response to the non-conserved sequence between H5 Indo        and H5 Vietnam was observed, but to a lower extend,    -   interestingly, the magnitude of these responses recognizing the        non-conserved sequences H5 Indonesia and the non conserved        sequence H5 Vietnam looked similar

Overall, the H5 specific CD4 T-cell response induced by the adjuvantedvaccine was strongest with the H5N1 Vietnam Split antigen, followed bythe H5 Vietnam peptide pool (Viet-Total), the H5 Vietnam and Indonesiaconserved (Viet-Indo Cons) and the H5 Vietnam and Indonesia nonconserved (Viet NC and Indo NC, there was no difference between the lasttwo).

TABLE 23 Descriptive Statistics on the frequency cytokine-positive CD4T-cells (per million T-cells) for the pool “Viet-Indo Conserved” antigenat Day 0 and Day 42 (ATP cohort for immunogenicity) Test Antigendescription Group Timing N Nmiss GM Mean SD Min Q1 Median Q3 Max POOLCD4-ALL HN8 PRE 43 6 10.89 64.19 102.02 1.00 1.00 26.00 76.00 460.00VIET- DOUBLES PII(D42) 44 5 131.98 194.50 118.61 1.00 116.50 179.50278.00 433.00 INDO HN4 PRE 43 7 29.99 85.00 84.77 1.00 5.00 77.00 113.00326.00 CONS PII(D42) 44 6 110.39 206.64 181.99 1.00 88.50 149.50 266.00724.00 HN8AD PRE 43 7 40.25 121.42 136.84 1.00 15.00 92.00 184.00 750.00PII(D42) 43 7 323.19 537.63 446.13 1.00 227.00 434.00 717.00 2408.00HN4AD PRE 42 8 16.26 151.31 348.68 1.00 1.00 27.00 165.00 2163.00PII(D42) 44 6 350.50 527.14 407.58 1.00 220.00 426.00 666.50 1891.00CD4- HN8 PRE 43 6 10.43 58.47 94.73 1.00 1.00 22.00 73.00 460.00 CD4OLPII(D42) 44 5 115.41 186.39 119.66 1.00 93.50 166.50 282.00 456.00 HN4PRE 43 7 33.34 82.84 81.68 1.00 23.00 59.00 120.00 300.00 PII(D42) 44 695.93 201.57 176.68 1.00 86.00 138.50 286.50 689.00 HN8AD PRE 43 7 37.09114.14 134.05 1.00 18.00 92.00 166.00 778.00 PII(D42) 43 7 307.01 509.12432.32 1.00 238.00 377.00 672.00 2350.00 HN4AD PRE 42 8 19.78 139.95301.66 1.00 1.00 40.50 133.00 1864.00 PII(D42) 44 6 332.42 508.50 396.321.00 215.50 424.00 642.50 1891.00 CD4-IFN-γ HN8 PRE 43 6 5.13 23.5636.07 1.00 1.00 1.00 37.00 148.00 PII(D42) 44 5 23.07 65.30 70.44 1.003.50 52.50 98.00 349.00 HN4 PRE 43 7 14.87 48.51 67.28 1.00 1.00 34.0054.00 384.00 PII(D42) 44 6 17.74 52.55 53.47 1.00 1.00 37.00 80.00197.00 HN8AD PRE 43 7 10.90 36.74 43.71 1.00 1.00 24.00 54.00 169.00PII(D42) 43 7 68.02 142.05 217.10 1.00 40.00 70.00 218.00 1388.00 HN4ADPRE 42 8 7.42 64.48 134.51 1.00 1.00 1.00 62.00 697.00 PII(D42) 44 650.81 105.84 116.34 1.00 33.50 62.50 149.00 660.00 CD4-IL2 HN8 PRE 43 610.05 59.26 93.00 1.00 1.00 21.00 88.00 459.00 PII(D42) 44 5 85.32147.82 99.74 1.00 77.00 141.50 228.50 434.00 HN4 PRE 43 7 24.98 74.8880.87 1.00 3.00 50.00 122.00 272.00 PII(D42) 44 6 99.53 186.34 169.031.00 89.00 142.00 222.00 752.00 HN8AD PRE 43 7 24.32 85.09 84.59 1.001.00 62.00 153.00 279.00 PII(D42) 43 7 330.45 467.56 375.07 27.00 175.00373.00 656.00 1743.00 HN4AD PRE 42 8 17.88 118.31 253.10 1.00 1.00 41.50132.00 1565.00 PII(D42) 44 6 277.78 456.34 378.28 1.00 180.00 371.00616.50 1888.00 CD4- HN8 PRE 43 6 10.10 52.05 74.44 1.00 1.00 16.00 76.00293.00 TNFA PII(D42) 44 5 65.28 128.70 97.03 1.00 34.00 131.50 211.50369.00 HN4 PRE 43 7 12.12 58.30 80.40 1.00 1.00 25.00 102.00 309.00PII(D42) 44 6 44.84 129.00 116.24 1.00 29.00 111.00 228.00 392.00 HN8ADPRE 43 7 39.83 98.26 136.53 1.00 25.00 60.00 129.00 806.00 PII(D42) 43 7193.36 364.91 299.01 1.00 121.00 309.00 555.00 1409.00 HN4AD PRE 42 814.77 124.02 304.56 1.00 1.00 21.00 106.00 1897.00 PII(D42) 44 6 243.66351.84 268.81 1.00 154.50 285.00 429.50 1176.00 HN8 = H5N1 7.5 μg HN4 =H5N1 3.8 μg HN8AD = H5N1 7.5 μg + AS03 HN4AD = H5N1 3.8 μg + AS03 N =number of subjects with available results Nmiss = number of subjectswith missing results GM = Geometric Mean SD = Standard Deviation Q1, Q3= First and third quartiles Min/Max = Minimum/Maximum

TABLE 24 Inferential statistics on the frequency cytokine-positive CD4T-cells for the pool “Viet-Indo Conserved” antigen at Day 0 and Day 42(ATP cohort for immunogenicity) P-value Groups compared Test descriptionPRE PII(D42) Dose effect HN8 and HN4 CD4-ALL DOUBLES 0.0313 0.6462CD4-CD4OL 0.0142 0.7606 CD4-IFN-γ 0.0114 0.4762 CD4-IL2 0.0618 0.6432CD4-TNFA 0.7373 0.8053 HN8AD and HN4AD CD4-ALL DOUBLES 0.1621 0.9155CD4-CD4OL 0.2901 0.8886 CD4-IFN-γ 0.4640 0.3591 CD4-IL2 0.5114 0.9020CD4-TNFA 0.1023 0.8618 Adjuvant effect HN8AD and HN8 CD4-ALL DOUBLES0.0057 <0.0001 CD4-CD4OL 0.0041 <0.0001 CD4-IFN-γ 0.0672 0.0086 CD4-IL20.0432 <0.0001 CD4-TNFA 0.0085 <0.0001 HN4AD and HN4 CD4-ALL DOUBLES0.4136 <0.0001 CD4-CD4OL 0.6009 <0.0001 CD4-IFN-γ 0.1774 0.0083 CD4-IL20.6957 <0.0001 CD4-TNFA 0.7129 <0.0001 HN8 = H5N1 7.5 μg HN4 = H5N1 3.8μg HN8AD = H5N1 7.5 μg + AS03 HN4AD = H5N1 3.8 μg + AS03 P-value =Kruskal-Wallis Test

In conclusion, AS03 in combination with the potential pandemic strainA/Vietnam was able to stimulate a cell mediated immune response with thetwo lowest antigen doses tested. In addition, the response observed inthe adjuvanted groups was stronger than the CD4 response induced by thenon-adjuvanted groups. Moreover, the adjuvanted groups with the lowestantigen content showed a higher response also against the antigenicallydifferent Indonesia strains (conserved peptide sequence): with theexception of IFNγ, a significant higher response in comparison to thenon-adjuvanted group could be shown. The results obtained for thecell-mediated immune response therefore confirm the results of theserology with responses elicited against the vaccine strain and theantigenically different non-vaccine strain by the adjuvanted vaccine.

IV.7.1.6 Influenza Specific B Cell Memory

Influenza specific memory B cells (Antigen: H5N1 A/Vietnam/1194/2004)were measured in the two lowest dose groups with and without AS03adjuvant. Results (Tables 25 and 26) have been expressed as a frequencyof Flu-specific memory B cells within a million of memory B cells.

In summary, pre-vaccination frequencies of influenza-specific B cellmemory were present at a similar level in the four groups (3.8 and 7.5μg with and without AS03). The induction of influenza-specific B cellmemory responses was significantly higher in adjuvanted groups. Noantigen-dose effect was detected on the CMI response in terms ofinfluenza-specific B cell memory.

TABLE 25 Descriptive Statistics on the frequency of memory B cellspecific to H5N1 antigen (per million memory B Cells) against vaccinestrain (A/Vietnam) (ATP cohort for immunogenicity) N Group Timing N missGM Mean SD Min Q1 Median Q3 Max HN8 PRE 36 13 1451.45 2118.67 1660.59101.00 779.00 1656.50 3058.00 5672.00 PII(D42) 38 11 3652.78 4549.212933.64 660.00 2185.00 4144.50 5741.00 11463.00 HN4 PRE 41 9 1441.162634.88 2944.67 71.00 730.00 1566.00 3179.00 14835.00 PII(D42) 40 102981.20 4164.95 2973.37 142.00 1983.50 3523.00 5446.50 11390.00 HN8ADPRE 39 11 1732.49 2670.28 2163.99 56.00 1084.00 2146.00 4101.00 9696.00PII(D42) 37 13 6557.32 8124.30 5777.05 1087.00 4962.00 6698.00 9776.0030346.00 HN4AD PRE 38 12 2166.36 3193.68 2832.49 405.00 1186.00 2270.504223.00 12147.00 PII(D42) 36 14 7639.18 9696.64 6018.86 469.00 5177.008765.00 12955.50 24092.00 HN8 = H5N1 7.5 μg HN4 = H5N1 3.8 μg HN8AD =H5N1 7.5 μg + AS03 HN4AD = H5N1 3.8 μg + AS03 N = number of subjectswith available results N miss = number of subjects with missing resultsGM = Geometric Mean SD = Standard Deviation Q1, Q3 = First and thirdquartiles Min/Max = Minimum/Maximum

TABLE 26 Inferential statistics on the individual difference between thepost- vaccination (Day 42) and PRE (Day 0) of frequency of memory B cellspecific to H5N1 antigen (per million memory B Cells) against vaccinestrain (A/Vietnam) (ATP cohort for immunogenicity) P-value Groupscompared PII(D42)-PRE Dose effect HN8 and HN4 0.3255 HN8AD and HN4AD0.4470 Adjuvant effect HN8AD and HN8 0.0105 HN4AD and HN4 0.0001 HN8 =H5N1 7.5 μg HN4 = H5N1 3.8 μg HN8AD = H5N1 7.5 μg + AS03 HN4AD = H5N13.8 μg + AS03 P-value = Kruskal-Wallis Test

IV.8. Overall Conclusions IV.8.1. Reactogenicity and Safety Results

The leading candidate for the next influenza pandemic is the avian virusH5N1, which has resulted in a high mortality rate in cases ofbird-to-human transmission, although efficient human-to-humantransmission has not been fully confirmed. Should H5N1 demonstrate theability to spread efficiently from person to person combined with theglobal transport network, the outcome may feasibly be a widespreadinfluenza outbreak affecting a high percentage of individuals, leadingto increased mortality and morbidity in all countries.

Therefore, an immunologically effective and antigen sparing approach tovaccination has to be established to prevent potentially devastatingeffects of a pandemic. This can be achieved by using a suitableadjuvant, and for the first time, the immunogenicity enhancing effect ofa novel adjuvant on a H5N1 candidate vaccine could be shown in thistrial.

This study was designed to evaluate (1) the safety and reactogenicity inhealthy adults of an pandemic influenza candidate vaccine adjuvanted ornot with oil in water emulsion, i.e., AS03, (2) the antibody andcell-mediated immune responses.

Reactogenicity data show that the adjuvanted pandemic candidate vaccineinduced (independent from antigen content) more local and generalsymptoms than the non-adjuvanted groups. However, the safety profile ofall 4 adjuvanted groups was clinically acceptable. No serious adverseevent was reported.

From these results, it can be concluded that the reactogenicity andsafety profile of the pandemic candidate vaccine adjuvanted with AS03 issatisfactory and clinically acceptable.

IV.8.2. Immunogenicity Results

Regarding the immune response, the pandemic influenza candidate vaccineadjuvanted with AS03 exceeded with all antigen contents tested (3.8 μg,7.5 μg, 15 μg and 30 μg HA, H5N1 A/Vietnam/1194/2004) the requirementsof the European authorities for annual registration of split virioninfluenza vaccines (“Note for Guidance on Harmonisation of Requirementsfor influenza Vaccines” for the immuno-logical assessment of the annualstrain changes—CPMP/BWP/214/96) together with the “Guideline on dossierstructure and content for pandemic influenza marketing authorizationapplication, CPMP/VEG/4717/03”, currently used as basis for evaluationof pandemic candidate influenza vaccines.

The four different antigen contents for a adjuvanted pandemic influenzacandidate vaccine tested in this trial were immunogenic in the healthyadults, who developed a excellent antibody response to influenzahaemagglutinin as measured by HI (Table 27).

TABLE 27 EU standard for antibody Variable response HN30AD HN15ADHN7.5AD HN3.8AD Conversion >2.5 27.9 38.1 60.5 36.4 factorSeroconversion  >40% 85.4 95.9 90.0 82.0 rate (%) Protection rate  >70%84.0 90.0 95.9 85.4 (%) HN30AD = H5N1 30 μg + AS03 HN15AD = H5N1 15 μg +AS03 HN8AD = H5N1 7.5 μg + AS03 HN4AD = H5N1 3.8 μg + AS03

Data evaluating the cross reactivity towards an antigenically differentstrain, H5N1 A/Indnesia/5/05, with the Haemagglutinin inhibition assayindicating in addition a cross-priming of the vaccinees in theadjuvanted groups against a drifted strain. Serological measures werecompleted by evaluation using the neutralizing assay for homologous andheterologous strain. Also by neutralization assay the immunogenicity andthe cross-protective potential of the vaccine candidate could beconfirmed. Finally, CMI data collected are also in line with theserological results for response against the homologous and theheterologous starin tested.

In summary, 2 doses of the adjuvanted pandemic influenza candidatevaccine induce at the lowest tested dose of 3.8 μg HA a protective titeragainst the vaccine strain H5N1 A/Vietnam/1194/2004 in a very highproportion of subjects, markedly exceeding all FDA and EU licensurecriteria established for evaluation of immunogenicity of influenzavaccines, against the homologous Vietnam strain. Furthermore, more than75% of subjects receiving the lowest dose of the adjuvanted vaccineseroconverted for neutralizing antibodies against a drifted H5N1 isolate(H5N1-A/Indonesia/5/2005-clade 2), documenting the ability of thecandidate pre-pandemic vaccine to induce immunity against a driftstrain.

The results support the use of the described vaccine composition even atas low a dose as 3.8 μg HA, to achieve seroprotection in a pandemicsituation in which the pre-pandemic priming is performed with a vaccinecomprising a strain heterologous to the circulating pandemic strain. Inother words, the described composition can be used to prime forsubsequent responses to drifted pandemic strain(s). The results aresupportive of the use of the claimed composition in a heterologous andhomologous 1- and 2-dose prime-boost use of pandemic monovalent (H5N1)influenza vaccine adjuvanted with AS03:

-   -   priming of patients with one or two doses of the adjuvanted        vaccine containing one pandemic strain (e.g. the Vietnam        strain), at a selected dose, including a low HA amount,    -   followed several months later (e.g. 6 or 12 months later) by one        dose of i) either the same pandemic strain (e.g. Vietnam strain,        i.e., homologous prime-boost) or ii) an heterologous (e.g.        Indonesia strain, i.e., heterologous prime-boost) strain, given        as a boost.

The adjuvanted vaccine was shown to provide a substantial level ofimmune protection against different strains of H5N1, and this strongcross-immunity was shown to develop rapidly—just 6 weeks after the firstvaccine shot (two shots given 3 weeks apart). The value of thisadjuvanted vaccine will importantly lie in a situation in which pandemicis declared after individuals have been primed prior to or aroundpandemic onset once or twice with either the same strain or a straindifferent to the ‘pandemic’ strain.

Furthermore this pandemic or pre-pandemic vaccine has achieved a strongneutralizing antibody immune response 25 times greater than observedwith a non-adjuvanted vaccine, and this response was achieved with 12times less antigen than is required for a regular seasonal flu vaccine,validating its antigen-sparing effect: a low-dose vaccine means greaterproduction capacity now, making more vaccine available for stockpileand/or priming; and cross-protection in the vaccine means earlyvaccination (priming) of some priority groups could enhance overallpreparedness.

Example V—Pre-Clinical Evaluation of Adjuvanted and Unadjuvanted SplitInfluenza Vaccines (Comprising H5N1 Strain) in C57Bl/6 Naive Mice V.1.Experimental Design and Objective

This study investigated the humoral and cellular immune responsesinduced by H5N1 Split vaccines adjuvanted with AS03 in naïve mice. Theobjective of this experiment was to demonstrate the added value of theadjuvantation in order to increase the immunogenicity of an adjuvantedinfluenza vaccine compared to naïve mice immunized with PBS or theunadajuvanted H5N1 Split vaccines.

V.2. Treatment/Group and Vaccine Formulations

C57Bl/6 mice received two (28 days interval) administrations ofdifferent doses (3, 1.5, 0.75, 0.38 μg) of A/Vietnam/1194/2004 splitvaccine adjuvanted with AS03. Immune responses were compared to theadministration of two doses of the unadjuvanted split H5N1 vaccine (3μg). Sera were collected 21 days post-boost to evaluate the humoralresponse by ELISA and HI assay.

Groups of 10 mice per group (dose/mice) for the assessment of humoralresponse:

-   -   H5N1 Split AS03 (3 μg)    -   H5N1 Split AS03 (1.5 μg)    -   H5N1 Split AS03 (0.75 μg)    -   H5N1 Split AS03 (0.38 μg)    -   H5N1 Split Plain (3 μg)    -   PBS

V.2.1. Preparation of the Vaccine Formulations

V.2.1.1. Split H5N1 Adjuvanted with the Oil-in-Water Emulsion AdjuvantAS03A in a 1000 μl Dose.

Split H5N1 clinical batches at 60 μg/ml-30 μg/ml-15 μg/ml-7.5 μg/ml aremixed vol/vol with AS03A adjuvant (prepared as taught in Example 2).Injections occur within the hour following the end of the formulation.

V.2.1.2. Unadjuvanted Split H5N1 in a 1000 μl Dose (Plain).

TWEEN™ 80, TRITON™ X100 and Thiomersal are added to the Final BulkBuffer (PBS pH 7.2±0.3 prepared as taught in Example 3) in order toreach a final concentration of 230 μg/ml for TWEEN™ 80, 10 μg/ml forThiomersal (the added quantities taking into account their respectiveconcentration in the influenza preparation) and 35 μg/ml for TRITON™X100. After 5 min stirring, 30 μg of H5N1 strain (HA antigen) are added.The formulation is stirred for 30 minutes at room temperature.Injections occur within the hour following the end of the formulation.

V.2.2. Read-Outs

-   -   Anti-H5N1 IgG antibody titers at day 49, by ELISA    -   HI titers at day 49 by the Hemagglutination inhibition assay    -   CD4+ T cell responses at day 35 (7 days post-immunizations)

V.3. Results and Conclusions V.3.1. Humoral Responses (Anti-H5N1 ELISATiters).

As shown in FIG. 12, AS03-adjuvanted H5N1 split vaccines inducedsignificantly higher anti-H5N1 IgG antibody responses compared to miceimmunized with PBS or the unadjuvanted H5N1 vaccine (p value<0.00001)(GMT with [95% CI]=30,444 [7,461;5,992] with 0.38 μg split adjuvantedH5N1 vaccine versus 49 [73;29] for the 3 μg of unadjuvanted split H5N1one). No antigen dose response effect was observed between miceimmunized with different doses of AS03-adjuvanted H5N1 vaccines (pvalue>0.5).

V.3.2. Humoral Responses (HI Titers)

As shown in FIG. 13, AS03-adjuvanted H5N1 split vaccines inducedsignificantly higher anti-H5N1 HI titers to the homologous straincompared to mice immunized with the unadjuvanted H5N1 vaccine (GMT with[95% CI]=1,810 [541;416] with 0.38 μg adjuvanted split H5N1 vaccineversus 11 [10;5] for the 3 μg unadjuvanted split H5N1 one). No antigendose response effect was observed between mice immunized with differentdoses of AS03-adjuvanted H5N1 split vaccines. Nevertheless, a trend forlower anti-H5N1 HI titers (2-fold reduction) was observed between thehighest antigen dose (3 μg) (GMT with [95% CI]=3,620 [5,938;2,249]) andthe lowest dose (0.38 μg) (GMT with [95% CI]=1,810 [541;415]).

V.3.3. Cellular Immune Response (CD4+ T Cell Response).

As shown in FIG. 16, a clear difference was observed between CD4+ T cellresponses induced by non-adjuvanted H5N1 vaccine and adjuvanted H5N1vaccines for both doses of antigen (1.5 or 0.38 μg). No antigen doseresponse effect was observed between mice immunized with two differentdoses of adjuvanted H5N1 vaccines (1.5 or 0.38 μg).

In summary, immunogenicity studies in mice showed that AS03-adjuvantedH5N1 split vaccine induced significantly higher humoral (anti-H5N1 IgGand HI titers) and cellular (CD4+ T cell) responses compared to miceimmunized with PBS or the unadjuvanted H5N1 split vaccine. Thus forhumoral immune responses AS03 adjuvant clearly enhances vaccineimmunogenicity. No antigen dose response effect was observed for humoralor cellular responses between mice immunized with 3 μg to 0.38 μg HA ofAS03 adjuvanted H5N1 split vaccine. These data suggest that even lowerdoses of HA than evaluated here may be required to observe a doseresponse effect in this model. This finding further illustrates thepotent adjuvant activity of AS03 in this vaccine formulation andsupports antigen-sparing strategies and increased vaccine supply, inparticular in a naïve population that may require 2 vaccine doses forprotection.

Example VI—Pre-Clinical Evaluation of an Adjuvanted Pandemic SplitInfluenza Vaccines (Comprising H5N1 Strain) after Heterologous Challengein Ferrets VI.1. Rationale and Objectives

This study investigated the efficacy of H5N1 Split vaccines(A/Vietnam/1194/2004) adjuvanted with AS03 to protect ferrets against alethal challenge with the H5N1 heterologous strain A/Indonesia/5/2005.The objective of this experiment was to demonstrate the efficacy of anadjuvanted influenza vaccine compared to ferrets immunized with PBS orthe adjuvant alone.

VI.2. Experimental Design VI.2.1. Treatment/Group (Table 28)

Four groups of ferrets (n=6) (Mustela putorius furo) were immunizedintramuscularly with four different concentrations of A/Vietnam/1194/04(Clade 1, NIBRG-14) (15, 7.5, 3.8 and 1.7 μg) vaccine in combinationwith AS03 (standard HD, 250 μl/dose). Two control groups consisted offerrets immunized with either AS03 alone or the unadjuvanted A/Vietnamvaccine (15 μg). Ferrets were vaccinated on days 0 and 21. Sera werecollected on day 21 and 42 for analysis of serological responses.Neutralizing antibody titres to homologous (A/Vietnam/1194/04) orheterologous (A/Indonesia/5/05) virus were determined by neutralizationassay. Ferrets were then challenged on day 49 with a dose of 10⁵ TCID₅₀(50% Tissue Culture Infective Dose) of A/Indonesia/5/05 (clade 2). Lungtissues were collected after the challenge to assess virus shedding byvirus titration culture on MDCK cells. Data were expressed as TCID₅₀ pergram of lung tissue. On day 54, all surviving animals were euthanized.

TABLE 28 Antigen +/− Group adjuvant Dosage Route/schedule Othertreatment 1 AS03 alone IM Challenge H5N1 Days 0 and 21(A/Indonesia/5/05) Day 49 2 H5N1 Plain  15 μg HA IM Challenge H5N1 Days0 and 21 (A/Indonesia/5/05) Day 49 3 H5N1 AS03  15 μg HA IM ChallengeH5N1 Days 0 and 21 (A/Indonesia/5/05) Day 49 4 H5N1 AS03 7.5 μg HA IMChallenge H5N1 Days 0 and 21 (A/Indonesia/5/05) Day 49 5 H5N1 AS03 3.8μg HA IM Challenge H5N1 Days 0 and 21 (A/Indonesia/5/05) Day 49 6 H5N1AS03 1.7 μg HA IM Challenge H5N1 Days 0 and 21 (A/Indonesia/5/05) Day 49

VI.2.2. Preparation of the Vaccine Formulations

VI.2.2.1. Split H5N1 Adjuvanted with the Oil-in-Water Emulsion AdjuvantAS03A in a 5000 Dose

A premixed buffer is previously prepared in the Final Bulk Buffer (PBSpH 7.2±0.3, prepared as taught in Example 3) containing Thiomersal,TWEEN™ 80 and TRITON™ X100. Thiomersal and TWEEN™ 80 are added inquantities taking into account their concentrations in the strain. Thefinal concentration of Thiomersal is 10 μg/ml. Detergent are at aHA/detergent ratio of 0.13 for TWEEN™ 80 and 0.86 for TRITON™ X100.

The day of the immunizations 15-7.5-3.8 or 1.7 μg of HA (H5N1 strain)are added to the premixed buffer. After 30 minutes stirring, 250 μl ofSB62 emulsion (prepared as taught in Example 2) is added. Theformulation is stirred for 30 minutes. Injections occur within the hourfollowing the end of the formulation.

VI.2.2.2. Unadjuvanted Split H5N1 in a 5000 Dose (Plain)

A premixed buffer is previously prepared in the Final Bulk Buffercontaining Thiomersal (a/k/a THIMERSAL®), TWEEN™ 80 and TRITON™ X100 inorder to reach a final concentration of 230 μg/ml for TWEEN™ 80, 35μg/ml for TRITON™ X 100 and 10 μg/ml for Thiomersal The added quantitiestake into account their concentrations in the strain. The day of theimmunizations 15 μg of H5N1 strain (HA antigen) are added to thepremixed buffer. The formulation is stirred for 30 minutes. Injectionsoccur within the hour following the end of the formulation.

VI.2.3. Read-Out

-   -   Protection at D+5 Post challenge as measured by % protection        (number of ferrets alive/total number ferrets per group) (Table        29)

TABLE 29 Read-outs Readout Timepoint Analysis method Protection D + 5Post % protection (number of ferrets challenge alive/total numberferrets per group) Neutralizing Days 21 and 42 Neutralization assayantibody titers Viral shedding Day 49 to Day 54 Virus titration cultureon MDCK on lung tissue and throat/nasal swabs

VI.3. Results and Conclusions

Table 30 summarizes the protection data obtained in ferrets afterchallenge with a heterologous H5N1 strain.

TABLE 30 Protection of AS03-adjuvanted H5N1-vaccinated ferrets against achallenge with a heterologous H5N1 influenza virus. % of ferrets withNo. dead/ viral load per gram of total no. lung tissue (% <10² 10²TCID₅₀ < X < >10^(5.5) Vaccination regimen survival) TCID₅₀ 10^(5.5)TCID₅₀ TCID₅₀ Adjuvant alone 6/6 (0)  0 0 100 Unadjuv. H5N1 (15 μg) 6/6(0)  0 0 100 H5N1-AS03 (1.7 μg) 1/6 (83)  68 32 0 H5N1-AS03 (3.8 μg) 0/6(100) 50 50 0 H5N1-AS03 (7.5 μg)* 0/5 (100) 80 20 0 H5N1-AS03 (15 μg)0/6 (100) 84 16 0 *One animal immunized with 7.5 μg HA of the adjuvantedvaccine died after challenge with A/Indonesia. However, macroscopicexamination was not consistent with H5N1 infection-induced death and wasnot comparable with pathologic findings in control ferrets immunizedwith AS03 alone or the unadjuvanted vaccine. This animal was excludedfrom the analysis as not compliant to the protocol and not replaced byanother animal.

VI.3.1. Protection Data.

Following the challenge of ferrets with H5N1/A/Indonesia/5/05, allcontrol animals receiving adjuvant alone or non-adjuvantedH5N1/A/Vietnam/1194/04 vaccine died or were moribund and were euthanizedon days 3 or 4 (Table 30). In contrast, the majority of animalsimmunized with adjuvanted H5N1 split vaccine survived to the end of thechallenge phase on Day 5 and were protected against the lethal challengewith H5N1/A/Indonesia (Table 30). All ferrets who received two doses ofat least 3.8 μg of the AS03-adjuvanted H5N1/Vietnam (Clade 1) vaccinesurvived the lethal heterologous challenge. Furthermore, all except oneanimal survived the challenge in the group of ferrets who received thelowest dose (1.7 μg) of the AS03-adjuvanted H5N1 vaccine (see Table 30).

VI.3.2. Humoral Responses (Neutralizing Antibody Titers)

Serological assessments showed that the AS03-adjuvanted monovalent H5N1A/Vietnam/1194/04 split formulations induced a neutralizing antibodyresponse against the homologous H5N1 A/Vietnam strain (FIG. 14, upperpanel). Furthermore, AS03-adjuvanted H5N1 A/Vietnam vaccine inducedneutralizing antibody responses to the heterologous clade 2H5N1/A/Indonesia strain (FIG. 14, lower panel) while no neutralizingantibody response (<40) was observed in ferrets immunized with thenon-adjuvanted A/Vietnam vaccine or the adjuvant alone. Interestingly,97% of ferrets immunized with the H5N1/A/Vietnam vaccine adjuvanted withAS03 that showed neutralizing antibody titers to H5N1/A/Vietnam higherthan 40 were protected against a challenge with A/Indonesia (mortalityor viral shedding in the lung). Moreover, all ferrets with anti-H5N1A/Vietnam neutralizing antibody responses below 40 were not protected interms of mortality or viral shedding in the lung.

These data demonstrate the potential of this adjuvanted H5N1 splitvaccine to generate cross-reactive humoral immune responses against aheterologous H5N1 pandemic influenza strain.

VI.3.3. Viral Shedding after Challenge with HeterologousA/Indonesia/5/05 Virus

Viral load higher than 10^(5.5) TCID50/g of lung tissue was observed inthe lungs of all ferrets immunized with the adjuvant alone or withnon-adjuvanted H5N1 A/Vietnam/1194/04 vaccine (Table 30). Anantigen-dose dependent decrease in viral load was observed in allferrets immunized with adjuvanted vaccines (FIG. 15). In 70% of ferretsimmunized with adjuvanted H5N1 vaccines, no virus was detected (underthe limit of detection of 10² TCID₅₀/g of lung tissue) (Table 30).

TABLE 31 Viral shedding in upper respiratory tract (throat and nasalswabs). % animals % ≥ 10² Groups shedding virus TCID₅₀/ml Adjuvant alone100 83 15 μg Non-adjuvanted H5N1 83 83 H5N1 AS03 (1.7 μg) 33 33 H5N1AS03 (3.8 μg) 17 0 H5N1 AS03 (7.5 μg) 20 0 H5N1 AS03 (15 μg) 33 33

As shown in Table 31, 92% ferrets immunized with the adjuvant alone orthe non-adjuvanted H5N1 vaccine shed high levels of virus in the upperrespiratory tract (throat or nasal swabs) throughout the course ofinfection. Conversely, only 17% ferrets receiving AS03-adjuvanetd H5N1vaccines shed virus in throat or nasal swabs demonstrating a reducedrisk of viral transmission in ferrets receiving the AS03-adjuvantedvaccines. No ferrets immunized with 3.8 or 7.5 μg of AS03-adjuvantedshowed viral shedding >10² TCID₅₀ in throat or nasal swabs.

Importantly, it should be noted that most animals from placebo (PBS) andadjuvant only groups died or were euthanized on days 3 and 4, while mostanimals in the vaccinated groups survived through to euthanasia on day5. Consequently viral loads were not measured on the same day postchallenge for all animals.

In summary, these results show the potential of a split adjuvantedpandemic vaccine, such as H5N1/A/Vietnam formulated with AS03, to induceeven with as low a dose of antigen as 3.8 μg, a strong cross-protectiveresponse in ferrets against a lethal heterologous H5N1 virus fromanother genetic sublineage (such as A/Indonesia/5/05 virus). The ferretsin the two control groups, who received either adjuvant alone or anon-adjuvanted vaccine, were shown to be highly susceptible to H5N1influenza infection, and did not survive challenge with the driftedstrain. These data suggest that cross-protection may be mediated atleast in part by antigen-induced humoral immunity.

These data support the concept of pre-pandemic vaccination, in orderwords the use of an adjuvanted H5N1 vaccine produced from a strain (e.g.clade* 1 H5N1A/Vietnam/1194/04) that does not optimally matched thepandemic strain (e.g. clade 2 H5N1/A/Indonesia/5/05) for a pre-pandemicstrategy of vaccination. Such a pre-pandemic influenza vaccine beingeffective against different strains, offers the possibility to provideprotection both before, and in the months following, the declaration ofa pandemic.

1-27. (canceled)
 28. A method for protecting a human against influenzavirus infection, the method comprising the step of administering to thehuman a monovalent influenza vaccine composition comprising a low amountof influenza virus antigen or antigenic preparation from an influenzavirus H1N1 strain that is associated with a pandemic, or has thepotential to be associated with a pandemic, in combination with anadjuvant, wherein the low antigen amount does not exceed 15 μg of HA perdose, and wherein said adjuvant is an oil-in-water emulsion comprising ametabolizable oil, a sterol and/or a tocopherol, and an emulsifyingagent, and wherein said vaccine composition induces at least one effectchosen from the group of: (i) an improved CD4 T-cell immune response, ascompared to unadjuvanted formulation; (ii) an improved B cell memoryresponse, as compared to unadjuvanted formulation; and (iii) an improvedhumoral response, as compared to unadjuvanted formulation, against saidvirus or antigenic composition.
 29. The method as claimed in claim 28,wherein said CD4 T-cell immune response involves the induction of across-reactive CD4 T helper response or the induction of across-reactive humoral immune response.
 30. (canceled)
 31. The method asclaimed in claim 28, wherein said immune response or protection meetscriteria chosen from the group consisting of: at least one of the threeinternational regulatory criteria for influenza vaccine efficacy, atleast two of the three international regulatory criteria for influenzavaccine efficacy, and all three of the international regulatory criteriafor influenza vaccine efficacy.
 32. The method according to claim 28,wherein said immune response or protection is obtained after one or twodoses of vaccine.
 33. The method as claimed in claim 28, wherein saidvaccine is administered parenterally.
 34. The method as claimed in claim28, wherein said HA antigen amount does not exceed 10 μg per dose.
 35. Amethod for revaccinating a human against influenza virus infection,wherein said human was previously vaccinated with monovalent influenzavaccine composition comprising a low amount of influenza virus antigenor antigenic preparation from an influenza virus strain that isassociated with a pandemic, or has the potential to be associated with apandemic, in combination with an adjuvant, wherein the low antigenamount does not exceed 15 μg of HA per does, and wherein said adjuvantis an oil-in-water emulsion comprising a metabolizable oil, a steroland/or a tocopherol, and an emulsifying agent, wherein said vaccinecomposition for revaccination contains an influenza virus or antigenicpreparation thereof from an H1N1 strain that is associated with apandemic, or has the potential to be associated with a pandemic.
 36. Themethod as claimed in claim 35, wherein the composition used for therevaccination contains an adjuvant.
 37. The method as claimed in claim36, wherein said adjuvant is an oil-in-water emulsion adjuvant. 38-39.(canceled)
 40. The method as claimed in claim 35, wherein said vaccinecomposition for revaccination contains an influenza virus or antigenicpreparation thereof that shares common CD4 T-cell epitopes or common Bcell epitopes with the influenza virus or antigenic preparation thereofused for the first vaccination.
 41. The method as claimed in claim 35,wherein the first vaccination is made with an influenza compositioncontaining an influenza strain that could potentially cause a pandemic,and the revaccination is made with an influenza composition containing acirculating pandemic strain.
 42. A method of protecting a human from avariant influenza strain, said method comprising the step ofadministering to the human a monovalent influenza vaccine compositioncomprising a low amount of influenza virus antigen or antigenicpreparation from an influenza virus H1N1 strain that is associated witha pandemic, or has the potential to be associated with a pandemic, incombination with an adjuvant, wherein the low antigen amount does notexceed 15 μg of HA per dose, and wherein said adjuvant is anoil-in-water emulsion comprising a metabolizable oil, a sterol and/or atocopherol, and an emulsifying agent.
 43. The method as claimed in claim42, wherein the first influenza strain is associated with a pandemic orhas the potential to be associated with a pandemic.
 44. The vaccinecomposition as claimed in claim 28, wherein said tocopherol is presentin an amount of 1.0% to 20% of the total volume of said vaccinecomposition. 45-46. (canceled)